Research and discussion paper

Male Sexual Health: Kathoeys in the Lao PDR, South East Asia -

Exploring a gender minority

Serge Doussantousse and others

Contact authors    uploaded 28/7/2005






This paper explores transgender (TG) males, who are a sexual minority in the Lao PDR. In both the Lao PDR and Thailand transgender males are commonly known as Kathoeys or Ladyboys, and although research has been done on Kathoeys in Thailand (Totman, 2003), none has so far been conducted in the Lao PDR. Social sciences research in the Lao PDR is still developing, and so far the focus has been on ‘normal’ male and female studies and therefore this paper intends to begin to fill the gap in the literature


The impetus to explore and describe this sexual minority is the result of observations and meetings with Kathoeys that took place on a daily basis. One of the researchers who has been working in the Lao PDR in the field of AIDS and the other as an English teacher, were confronted by a ‘new’ sexual paradigm which challenges the binary polarities of the two genders of male and female that exists in Western Europe and North American culture. Although transgender males are found in Europe, their presence is marginal in comparison to the Lao PDR where they seem to coexist harmoniously within mainstream society. It is this situation that raised our curiosity, and as researchers we decided to focus our attention on this highly visible sexual minority.




This paper will report on preliminary, exploratory work undertaken in Lao PDR in 2003, which provided an opportunity to begin mapping the Kathoey culture. The paper explores Kathoey’s social integration, firstly within the family and secondly within Lao society. It will therefore focus on the environment and individuals involved in the socialisation of children such as parents, schoolteachers, and the community at large. The Kathoey’s childhood is an important stage, as sexual preferences are determined at an early age, and it is also the beginning of the transition when a boy or adolescent chooses to wear female attire. Examining the range of occupations held by Kathoey’s will be used as another way to determine their position and integration within mainstream society.


The health of Kathoey’s is the other main area of focus, both in terms of their sexual health (by examining their sexual practices and preferences, and their knowledge of sexually transmitted infections  HIV/AIDS) and also their physical health that may be at risk due to the consumption of drugs to bring about body modification. This paper aims to gain a better understanding of the position of Kathoey’s within a changing society, so that programmes which encourage safe sexual practices for example, can be more effectively directed at this group.


Introduction to Male Transgender


A male transgender is someone who feels like a woman but is trapped in a man’s body, and therefore he exhibits and favours female traits. The Lao Kathoey’s characteristics appear to be similar to other transgenders in the region which have been described in the available literature. (1) In some societies transgender behaviour, interests and identity tends to be seen as a difference (very often tolerated, often accepted, even sometimes welcomed), and not as a disorder. (1)


The majority of Transgender males are only attracted to men, and research in Thailand has shown that 91% of the research sample reported an exclusive attraction to men, with around 30% seeing such attraction as being heterosexual. (1)


Recent Thai research (1) has also found that while 46% think of themselves as being a woman, 47% think of themselves as kathoey or one of its related terms. A significant minority seem entirely happy to think of themselves in these terms. While around 70% would prefer to be a woman and indeed be re-born as one, 19% said that they would prefer to be a Kathoey (or its related terms); with 12% saying that they would want to be reborn as such.[i] No research to date has been carried out in the Lao PDR to record Kathoey’s perception of identity or preferences.


Lao society experiences external influences from other countries such as cultural and economic forces from Thailand as well as those resulting from political affiliation with Vietnam. In addition, westernisation, has been accelerated by the increasing numbers of tourists and expatriates travelling, living and working in the Lao PDR, and also due to a growing number of the Lao middle class going to study abroad. There is a risk that the position of Kathoeys might be undermined by these external influences. Our intent is not to alienate Kathoeys, but to gain a better understanding of their social integration and their needs.


Kathoeys are visible in the prostitution scene and therefore their behaviour and sexual practice in the time of HIV/AIDS and STI epidemic is of utmost priority.


Research Methodology


The pilot study was intended to test the overall approach, a semi-structured interview schedule and explore issues of access, sampling, reliability and validity.  This flexible and adaptable tool allows change and adapting to unexpected information.  In the context of Lao PDR where Kathoeys were hardly studied it gave the possibility to re-direct our initial questioning.  Kathoeys included in the research were people met during our social encounter.


Additional information was gathered from existing literature and from the Internet. Discussions about Kathoeys in the Lao PDR also took place with international organisations and individuals, including those involved with HIV prevention programmes. One of the researchers attended a conference on sexual health in Chiang Mai, Thailand in February 2004.


Kathoeys who answered the questionnaire were informed upon the possibility of withdrawing at any moment of the interview.  Their names were not taken.  We assured them about the confidentiality and anonymity of the research.




The research team carried out field observations with twelve Kathoeys in Savannakhet city and Vientiane. It was a convenient sample group that was contacted during social activities.

Three personal in-depth interviews took place using a semi-structured questionnaire. The in-depth interviews were conducted in a private setting and lasted for about two hours.  During the interview the respondents were confident and did not appear embarrassed. The interviews also went smoothly due to the assistance of a Lao translator.


Description of the sample


Interviews were conducted with individuals who labelled themselves as Kathoey.  They exhibited feminine traits with their mannerisms and appearance as they had long hair, used make up, and had a visible dress code particularly when going out at night. 


Twelve (12) respondents.


 Nine respondents were from Savannakhet, two from Vientiane, and one from Pakse.


17 to 25 years old.




Shop owner







Guest House owner


Market seller




Garment factory (line manager)


Floral arranger





          From provinces in the Lao PDR to Vientiane                              2

          From the Lao PDR to Thailand                                     4


Social Integration

The Developing Child


All the Kathoeys the research team interviewed stated that from their earliest recollections they associated themselves with girls. Therefore by the age of seven or eight and sometimes even younger the respondents started to identify themselves as girls. They mostly preferred to play with girls and didn’t particularly like to be with boys.

Most of the respondents told us they liked to use make-up and cross-dress from an early age using either their mother’s or sister’s items. There was no secrecy related these activities and no peer pressure seemed to be evident at this stage.

Complications do not appear to arise in Lao society when an individual insists that he or she adopts a manner of social expression (gender role) that he or she feels is inconsistent with what they are (gender identity).




None of the respondents remembered being stigmatised or being subjected to any parental constraints. However contrary to this information, we met one former Kathoey who had to revert to his original gender, because of parental pressure.

One of our research team members knew a Kathoey who committed suicide, because of a lack of understanding of his wishes which conflicted with his family’s expectations.


School and Friends


The respondents told us that during their time at school they were expected to dress as males, but predominantly chose to spend time with girls, by sitting next to them in class and studying with them. At school, they were allowed to use the female toilets without any objections from their female peers. The respondents did not feel that they were stigmatised, although their school mates and teachers did make fun of them in a friendly way. One of the researchers, being a teacher, observed that Kathoeys are very confident and popular with both male and female students in a classroom environment. They also tend to be humorous, lively and studious.  One of the students in the sample group reported that he dressed as a male whilst at school and then afterwards wore a long wig when socialising with his Kathoey peers.




After leaving school and its associated constraints, the respondents reported that they subsequently were able to start living as a Kathoey. Some of the respondents moved out of their family homes at the age of sixteen or seventeen, but they chose to do this in order to gain independence, as none of them reported that they experienced rejection from their relatives. The tendency was for the respondents who originated from rural areas to migrate to more anonymous urban areas. There were no reports of discrimination from the interviewees but the research team heard of cases of prejudice which need further evaluation.


Occupations and income


Most of the members of the sample group went into professions which are predominantly chosen by women such as beauticians, hairdressers and market vendors, and they appeared to enjoy and excel in these occupations.

One of our informants, the owner of a garment factory in Vientiane, which employs 600 people (who are mostly women), acknowledged that one of his best line managers is a kathoey. He reported that Kathoeys work faster than the women in his garment factory. We took the opportunity to interview the aforementioned Kathoey and she told us that she had a foreign partner who asked her to stop working at the garment factory and move in with him. This arrangement lasted for thirteen months during which he bought a motorbike for her and a farm for her family. When he left the country he sent her an average of 250 US, per month, but this only lasted for a period of three months. Eventually she returned to her former job as a line manager from which she generated an income of US$300 per month.  




One of the opportunities open to Kathoeys is to work as commercial sex workers servicing both the local and a foreign clientele. The research team observed that many Kathoeys involved in prostitution also had other means of income, which include the occupations mentioned in the previous section. One of our respondents told us that after she had moved to Vientiane she met about twenty other Kathoeys over a six month period.  She estimated that at least ten of the members of this group gained additional income as commercial sex workers. One of the respondents told us that during the week before the interview, she had three commercial encounters with the clients paying her a range of US$10, US$30 and 500 baht. Another respondent told us she earned a maximum of 2000 Baht or 70 $ a night for such services.




Body modification


According to our respondents, many Kathoeys use a range of methods to change their physical appearance besides growing their hair and wearing female garments.

These techniques include the ingestion of pills, the use of injections as well as surgery. Oestrogen is used to enhance their femininity, which is normally taken in the form of female birth spacing pills. This is the only hormonal treatment available at local pharmacies.  

A Lao medical doctor reported that Kathoeys chose to have their breasts injected with Depovera on a monthly basis for enlargement purposes.

Five of the respondents were or are currently using hormonal treatment for the purpose of body modification. The respondents told us that only a few of their kathoey friends had undergone Sex-Reassignment Surgery (SRS), or had made efforts to have their breasts enlarged. The majority of respondents stated that the decision of whether to undergo SRS is largely dependent on their lack of financial means to pay for this type of surgery. However one of the respondents did say that she was not interested in undergoing SRS because she felt that it could jeopardize the quality of her life.

Many of our respondents know a famous Kathoey in the Vientiane life who underwent SRS, and is now living with her foreign boyfriend in Switzerland.


First sexual experience


Three of the respondents were asked about their first sexual partner, and all of them reported that they had their first sexual experience as adolescents. Two of the members of this group of respondents had their first sexual experience with non-Lao nationals. One respondent stated that her first sexual encounter involved non penetrative sex and another respondent said that it involved oral sex. However the latter respondents said that after watching a pornographic movie, which her foreign partner had procured, she started having penetrative sex.

The other respondent from the southern province of Pakse told us that when she was in her early twenties she had to offer gifts and presents as part of her efforts to seduce a Lao boy who was of a similar age. He was aware of the fact that she was a Kathoey and after going out together for two months they eventually had sex. This involved him performing anal sex on her without the use of condoms, as well as her performing oral sex on him. During the sexual act the boy asked her if she would mind hiding her penis. The boy was never presented to her family and nor was she presented to his, indicating that they did not perceive each other as permanent partners.  This was the only sexual contact she with this particular boy and she then had a non-Lao national as her second sexual partner. 


Sexual practices and other risks


According to the information given by the participants in this study, the Kathoey’s sexual practices are in line with those of homosexual men as they have anal and oral sex as well as mutual masturbation. They are usually penetrated and they will penetrate their partner if asked to do so, although this does not appear to be the most frequent or popular asexual activity


The respondents had used condoms with their foreign partners, but on some occasions decided against using them if their partner was particularly generous or charming. All of the respondents showed knowledge of HIV/AIDS, but their sexual practices often do not take preventative measures for HIV/AIDS transmission into consideration. One respondent stated that she believes that it is safer to wash her hands before and after sex, but we are unsure of the foundation of this knowledge.


It is worth noting that an international organisation has started marketing a package of two condoms which includes a pack of lubricant in the Lao PDR, with the objective of ensuring safe anal sex. On Valentine’s Day the aforementioned organisation generously distributed free condoms at a nightclub in Vientiane which is popular among the city’s Kathoey community.


A Lao doctor who was interviewed reported that although he has a lot of male and female patients who have sexually transmitted infections (STI’s), none of them would be classified as being Kathoeys. He offered the explanation that Kathoeys may not be aware of anal infections. The research team therefore believes that Kathoeys may be seeking treatment for STI’s from other practices. It has been noted in a recent study on male sex workers in the Lao PDR that men involved with prostitution are suffering from oral sexual transmitted infection. It is a matter of concern that these infections have not been identified among the Kathoey community in the Lao PDR.

The research team is aware of at least three Kathoeys in Savannakhet province who are infected with HIV/AIDS. The number of Kathoey’s seeking HIV/AIDS tests and information on HIV/AIDS and STI’s, as well as those already infected, are at present unknown, because they are not recorded as such in national surveillance data.


These physical matters of concern have not yet addressed psychological problems that could exist among members of the Kathoey community. As has been noted earlier with the case of the suicide victim, that there are external pressures that Kathoeys may be subjected to, which could have drastic consequences. To date no research has been conducted on their mental health or on alcohol and drug abuse among Kathoeys in the Lao PDR. 


Source of information


Among our sample the initial knowledge about women issues came from preference to being among females, mother, sisters and girlfriends from an early age.

Afterwards, they gain more information from their network of Kathoey friends and eventually, those who have foreign boyfriends or travel out side of Laos, get additional information.

One of our respondents told us she had taken part in a sex education show, directed to inform all students about HIV prevention and demonstrating the usage of condoms whilst still at school.

Parallel to the general education, our respondents got advise from individuals, one was advised, by a relative that is a doctor, about the use of hormones, another was advised by a neighbour to use condoms because she was known to have many partners.

They gain additional information from organisations that promote the usage of condoms in high risk groups, such as female prostitutes but currently there aren’t any programmes of education targeting the specific group of Kathoey in Laos. Thailand




This preliminary paper shows that more extensive and rich information is needed about Kathoey in Laos. The numbers of Kathoey in Laos are difficult to assess, the number of Thai kathoey are put as high as 300,000[ii] and may be evident in many different social groups and categories. It seems a significant number of young boys; feel feminine and want to be perceived as females.

Kathoey appear to consider themselves as a woman in a man’s body; as such they have to exaggerate their attitude to show they are also women. Their joviality and happiness supporting their mannerisms is a way to cross their biological gender. Sometimes Kathoey use attitude and wear dresses that a normal woman would not wear or wouldn’t be an accepted form of dress to wear 

The research team perceives a high level of acceptance in Lao families and the community at large, but conflicting information shows the need for further research. Kathoey are present in all kinds of female activities. They are seen in all walks of life in Lao but Kathoey are more present in the private sector of the economy and only marginally among professional and governmental officers.  But their visibility on the prostitution scenes does not mean they are locked in to this kind of occupation but use it as an addition to a more legal income.

Their knowledge about HIV and STI infection seems scant compared to the risks of their sexual practices.  Knowledge acquired through the general media, through the campaign targeting female prostitution, from word-of-mouth with other Kathoey in Laos and Thailand, and for those having foreign partners, but this does not seem enough.

We need more information about the risks of infection linked to their sexual practices.  More investigations are needed, and not only in Vientiane, though this city attracts numerous Kathoey from all over the country. There appears to be larger isolated pockets of Kathoey in some provinces, what numbers and why this should be the case, is at present unknown.

We have little information about migration from Laos to Thailand though there is more research done on Lao women working in the sex industry in Thailand.  It seems that Thailand attract Kathoey as well.

Some of those interviewed had travelled aboard with their foreign partners, to places like Germany and Thailand. And our respondents know of at least one now living in Switzerland with their foreign partner.

There is looser control of pharmaceutics in Laos, which means that for those Kathoey who choose to make body modifications, the only barrier is expense. The use or misuse of hormone treatment seems well spread among Kathoey in Laos; the risks taken are not well understood.




It’s been noted in recent Thai research (1), that Kathoey develop cross-gendered identity before developing a sexual preference. Is this the same in Laos and what influences this? With our limited pilot research, it seems than the findings are similar to the Thai research. What influences these young boys is yet to be determined in Laos, through further research.

More research is needed on male sexuality in Laos, especially this group of men called Kathoey.  Little is known about their lifestyle and practices.  Though their integration seems normal, the risk in a changing society may lead Kathoey to being discriminated against and ostracised. With the increase of tourist development in Laos, there is a larger than ever number of tourists visiting Laos, this brings its own challenges to a sexual minority.  Lao society looks like a very tolerant society and accepts this third gender naturally.  But no specific HIV and STI prevention activities target Kathoey as such though they get information through the mainstream.

Life in the urban areas seems to attract many Kathoey; more information is needed in rural areas and among minorities where little is known about Kathoey.

It is crucial that educational material should be designed specifically targeting Kathoey, and they should be employed as educators. Peer education through Kathoey should be organised to improve the access to adapted information.

Besides studying Kathoey life, interviewing Kathoey’s parents is an utmost priority to better understand the specificity of Laos and its Kathoey population.  Employing Kathoey as key informant and researcher will facilitate this task.

However, it is essential that more information is obtained on the estimated numbers of Kathoey and what influence these numbers, those infected or put at risk with HIV and / or STI’s, and their sexual practices.




Whilst there are some similarities with the sub-cultural experiences of transgender males in Thailand, this preliminary paper shows that little is known about Kathoey in Laos. The numbers of Kathoey are difficult to assess. It seems a significant number of young boys feel feminine and wants to be perceived as females.

The traditional society in Lao seems to have been accepting and tolerant of transgenders, and Kathoey are seen in all walks of life although their professional activities are related to female occupations. Increasing tourism and globalisation are effecting changes that might adversely affect Kathoey, making the cultural climate much less tolerant of sexual groups that are socially constructed as ‘deviants’ or subversive to the gendered binary polarity of western societies. s therefore important to gain more information about Kathoey in Laos, to enable to help further educate and protect this group of vulnerable people. They appear to be misusing drugs to feminize themselves and their inadequate prevention techniques of HIV and STI’s are worrying.




Totman, R. (20030 The Third Sex: Kathoey – Thailand’s Ladyboys, Silkworm Books: Chiang Mai


Winter, S., Thirteen general proposition about TG in Asia Division of Learning, Development and Diversity, Faculty of Education, University of Hong Kong, Hong


[i] Sam Winter, Thirteen general propositions about TG in Asia

[ii] Sam Winter, Thirteen general propositions about TG in Asia