It was nearly 40 years after Trin Pattanaweroj realized he had been born in the wrong body for him to be able to do something about it. And then, it took years of savings plus a large severance check to pay the THB1 million (US$30,000) necessary to align his body with his identity.
“With this huge amount of money, other people might as well buy a house or a car,” said Trin, now 48. “But for me, I have to pay for my gender-affirming care because it’s not covered by the government.”
That cost – nearly 70 times Thailand’s average monthly income of THB15,200 – is an insurmountable barrier for many Thais. But it could soon fall as the government quietly considers extending its universal health care program to cover gender-affirming treatment and other LGBTQ+ services, an effort closely watched in neighboring countries where scant services exist.
Since he was as young as 6, Trin knew that he liked to keep his hair short. He never wanted to wear skirts or play with dolls like most other girls. And when puberty hit, and Trin’s breasts started to develop, he didn’t like what he saw in the mirror.
“I told my mom, ‘I don’t want to live in this body,’” Trin said.
One day, Trin flicked on the television and saw an openly transgender man on a reality show. He had close-cropped hair, a bearded chin, flat chest, and deep voice – exactly the kind of man Trin wanted to become. That’s when Trin realized that he could become what he was always meant to be.
“I was amazed and excited. I was like, ‘Wow, transitioning from female to male exists?’ That’s exactly what I want to do,” he said.
But he had no idea that getting there would come at such a great cost. It took six years and numerous medical procedures for Trin to change his physique.
After his first injection of the hormone testosterone, Trin started to sprout facial hair. His voice sank into deeper and lower pitches. Trin went on to remove his breasts (THB55,000) and uterus (THB28,000). Last year, he undertook the final surgery: phalloplasty, or construction of a penis (THB600,000).
Trin is not sure how many others like him are out there. While trans women are very visible in Thai society, there is little awareness or recognition of trans men. They have never been counted by demographers and lack community.
The cost of transitioning is an even harsher economic burden for those with lower incomes for whom the necessary belt-tightening can be literal, like 33-year-old Thanadech Jandee.
“I had to be extremely frugal. I used to eat one meal a day, keeping my expenses as low as THB100 (US$3) per day,” said Thanadech, who rides a motorcycle for Grab, a ride-sharing company popular across Southeast Asia. “Sometimes I even resorted to starving myself to save enough money.”
‘Government needs to fund our health care’
Despite the common association that Thailand is some kind of gay paradise, stigmas and discrimination persist against its lesbian, gay, bisexual, transgender, and queer citizens. When it comes to health care, that discrimination is economic.
Working to address that has been a group of LGBTQ+ health practitioners and advocates pushing for their health needs to be covered by Thailand’s vaunted universal health care program.
“We’re left behind, way behind,” said Kritima “Jemma” Samitpol, who supervises Tangerine Clinic, a transgender health center in Bangkok. “There is no solid policy that caters to the population. Even though there are health care services for gender-affirming care, it’s neither affordable nor LGBTQ-friendly.”
They believed a simple policy change would be the best way to make health care truly universal, and now their quiet campaign is poised to pay off.
“That’s why we came up with an idea that, to solve the problems more sustainably, the government needs to fund our health care,” Jemma said.
Health is considered crucial for sustainable human development. Regarded as a health-for-all solution, universal health care is hailed by the World Health Organization (WHO) as a tool that grants people “the full range of quality health services they need, when and where they need them, without financial hardship.”
In 2002, Thailand became one of the first middle-income nations to introduce universal health coverage, allowing all citizens access to care for only THB30 (US$1). It is funded entirely by taxpayers and allocated on a per-capita basis by the National Health Security Office, or NHSO.
‘The government needs to fund our health care’: LGBTQ+ clinic supervisor on making Thai health care truly universal (Interview)
Yet, 20 years later, the program still fails to cover any form of gender-affirming care beyond AIDS/HIV testing. The basic, gender-affirming needs of transgender people such as hormone therapy and blood tests are still not covered under the much-lauded system.
In 2020, Jemma and her colleagues petitioned the NHSO to add gender-affirming counseling and care to the public health care program.
Their office gave its response: It agreed.
“It marked the first time in history,” Jemma said.
After the successful pitch, critical steps – and bureaucratic due diligence – followed. Over two years later, Jemma and her colleagues are conducting more research into how to make the coverage accessible and effective. They will present their findings to the NHSO board for consideration within two years. If approved, LGBTQ+ health care services will be covered by Thailand’s government health care program, meaning treatment will be either free or very affordable nationwide.
Jemma estimated that it should take under two years partly because the logistics are already in place.
“Hormonal replacement therapy is already common for treating women with menopause or aging males,” Jemma said. “The idea is similar for some transgender people – they need regular hormone monitoring and health checkups.”
“We just need to adapt a little bit and define our target, make it more gender-inclusive and friendly,” Jemma said. “It won’t need much financial investment. We just use the resources we already have, apply and adapt them to cover more populations in the country.”
She has seen the demand for such services firsthand.
Since its opening in late 2015, the clinic she manages – billed as the first community-led transgender health clinic in Thailand and Asia – has treated more than 5,000 transgender patients. Ninety percent of its clients were Thai while the rest hailed mostly from Japan, Russia, Myanmar, Laos, Malaysia, and the Philippines.
In the future, after the health care program is expanded, Jemma hopes that at least one hospital in every Thai province will offer LGBTQ+ health care services. Stakeholders should also invest in telehealth, she said, to increase access for those in rural and remote areas.
Jemma said it would be the most sustainable solution.
“It will unlock so many problems,” Jemma said. “LGBTQ+ people will get appropriate access to professional advice, hormonal therapy, checkup, and so on. If they want to see a psychiatrist or specialists, we’ll be able to refer to them right away.
When life-changing is life-saving
In Thailand and beyond, improving access to LGBTQ+ health care – physical and mental – is not only medically necessary but can also be life-saving for many LGBTQ+ individuals.
Thai LGBTQ+ youth are at greater risk of depression and suicide than their peers and adults. A recent study by the Save the Children Foundation and two Thai universities found that up to 80% of LGBTQ+ Thais 15 to 24 experienced anxiety and depression. The research also found that 58% had suicidal thoughts while 60% attempted suicide. Twenty-five percent said they had inflicted self-harm.
An extensive 2016 study in the Philippines found LGBTQ+ youth there were also at an elevated risk of suicidal thinking and attempts. A 2017 Indonesian study found there simply was not enough information to make any conclusions.
Gender dysphoria is the distress caused by a mismatch between biological sex and gender identity. Harvard Medical School research published last year in the Journal of the American Medical Association found gender-affirming surgery led to better mental health.
“Gender-affirming care is often viewed as something for beauty purposes only, but actually it’s far from it,” said Jiraporn Arunakul, a physician at the Gender Variation Clinic.
At the Gen-V Clinic, located at the public Ramathibodi Hospital in Bangkok, pediatricians and adolescent psychiatrists provide care and consultation for LGBTQ+ children, teens, and their parents.
Without such professional, medically supervised care, transgender people have taken treatment into their own hands. Some administer their own hormones, which poses serious health risks of misuse or overdose if not professionally monitored.
For the transgender residents of some of Thailand’s more culturally conservative neighbors, where sexuality and gender identity are taboo subjects, there are even fewer options to treating oneself.
“In Indonesia these days, we still see trans women die from silicone injections,” said Alegra Wolter, Indonesia’s first openly trans doctor. She works at the Angsamerah Clinic and is also an LGBTQ+ rights activist in the capital city of Jakarta.
Silicone injections, or “pumping” is a common procedure trans women use to create a more feminine appearance. The injections – made to the hips, buttocks, thighs, breasts, or face – may lead to infection or acute systemic inflammation. The liquid can even leak into the bloodstream and travel to the lungs or heart, to fatal effect.
According to Wolter, many transgender Indonesians are still subjected to deeply rooted stigmas and discrimination. A lot of them, she said, cannot access the formal medical system due to a variety of reasons, including social norms and religious values.
Indonesia is the world’s largest Muslim-majority country, and LGBTQ+ people are routinely targeted by religious hardliners.
“There are patients who are rejected from hospitals because they are transgender. Even some physicians don’t want to help transgender patients because of their religious values,” Wolter said. “This is why a lot of transgender people cannot access the formal medical system, so they decided to transition themselves. Sometimes, they inject hormones with correct doses or, mostly, not correct doses.”
Like Thailand, cost is an issue. Unlike Thailand, Indonesia still does not have a specialized gender health clinic. It only has a referral system directing transgender patients to private hospitals or clinics where services cost more than at public facilities.
Wolter opines that Indonesia needs to step up and bring together health care professionals, government, non-governmental organizations, and local LGBTQ+ stakeholders.
“It should be a cross-division collaboration – one that transcends beyond research and be implemented at once,” Wolter said. “We can establish a proper health program inside a health facility that caters to the trans community, just like what Tangerine Clinic has been doing.”
Because in Indonesia, she said, it’s all too often a life and death matter.
“We need to do this, because people are dying of not getting the right support. People are already transitioning themselves, why don’t we give them proper information and proper care in a safe way?”
‘A beautiful beginning’
Last year Bangkok elected reformist governor, Chadchart Sittipunt, who plans to provide LGBTQ+ health care at the public clinics and hospitals it manages. Eleven “BKK Pride Clinics” are planned across the capital city, according to deputy governor Tavida Kamolvej.
As the first community-led transgender health clinic in Asia and Thailand, Tangerine Clinic has already paved the way. In addition to direct services, it also trains LGBTQ+ organizations to improve their offerings. Some locations are even outside Bangkok in historically underserved areas such as the northern city of Chiang Mai and southernmost provinces of Songkhla, and Pattaya.
“It’s clear that we cannot do this alone. There are potential organizations out there. All we do is help them to improve the services,” Jemma said.
Jemma and her colleagues also work with health care workers in other countries such as Myanmar, Vietnam, Sri Lanka, Nepal, and The Philippines, where similar efforts are underway.
“As Thailand is trying to achieve universal health care for LGBTQ+ people, we are trying to do the same in The Philippines,” said Aisia Castelo, a human rights defender at Amnesty International Philippines and a volunteer at Love Yourself Clinic, a Manila nonprofit that aims to destigmatize HIV/AIDS. The clinic provides HIV testing, counseling and treatment to men who have sex with men.
But in the Philippines, where over 80% of the population identifies as Roman Catholic, a heavy strain of reactionary politics is a source of adversity for LGBTQ+ Filipinos.
According to Castelo, gender-affirmative care in The Philippines is still “very limited” due to lack of comprehensive and affordable transgender services coupled with stigma and discrimination toward LGBTQ+ people. Consequently, she said many LGBTQ+ Filipinos are forced to self-medicate and seek third-party sources for guidance and “gray market” medication.
“Unlike Thailand, we cannot go to pharmacies to purchase Androcur because it’s not FDA-approved,” Castelo said, referring to a medication commonly used to reduce trans women’s response to testosterone.
Improving the lives of their LGBTQ+ compatriots cannot be achieved without landmark legislation – something the Filipino LGBTQ+ communities and their allies have been fighting for.
They are trying to get the health care sector to formally recognize LGBTQ+ services in mainstream package benefits such as Philippine Health Insurance Corp., aka PhilHealth, something Castelo notes would be a “starter conversation.”
She said something else is needed first: the health department’s green light.
“To be able to do this we first need guidelines on transgender health from the Department of Health before facilitating insurance coverage,” Castelo said. “That in itself is gonna take a while, considering that we cannot even pass the Anti-Discrimination Bill for which we’ve been lobbying for two decades.”
After two decades of pushing for the passage of an Anti-Discrimination Bill adopted by the lower house in 2017, its sponsor in the upper house, Sen. Risa Hontiveros, said in December that she was hopeful it would eventually move forward.
If the bill becomes law, it will make it illegal to deprive someone of employment because they are gay; or deny anyone access to emergency health services because of their gender expression.
For these reasons, eyes are on Thailand’s progress toward covering gender-affirming care in its signature national health program. And those who continue to make great sacrifices to obtain the care they need, like Trin and Thanadech, hope that day comes soon: Both men are still paying out of pocket for the testosterone they must take for the rest of their lives.
“I hope that at least Thailand can make hormonal therapy a primary treatment that’s free for everyone,” Trin said. “If that can happen first, it’d already be a beautiful beginning.”
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