Research and discussion paper


The health risk and health care seeking behaviors of male-to-female transgender persons in Khon Kaen, Thailand. First implications for targeted prevention.

Luhmann N, Laohasiriwong W. 

(uploaded 19/09/06)


This study has been conducted in order to finish the Masters Program in International Health at the faculty of Public Health, Khon Kaen University, Thailand and the Institute of International Health, Humboldt University, Berlin, Germany. It was supported by a three months scholarship of the Erasmus Mundus Program of the European Union.



Objectives: To describe the most important health risk behaviors and health care seeking patterns among male-to-female (MTF) transgender persons in Khon Kaen, Thailand.

Methods: For the descriptive survey 67 MTF transgender persons were identified through snowball-sampling. Participants were 18 years or older, self-identified as MTF transgender, were able to read and speak Thai and were residents of Khon Kaen Province, Thailand. Demographic and behavioral data were collected, using a self-administered questionnaire.

Results: Mean age was 26.3 (SD=5.6) and a majority (70.1%) had achieved more than high school as highest educational level. 85.1% had taken cross-sex hormones before and had started at a mean age of 16.4 (SD=2.96) years. 79.1% were taking hormones at the time of the assessment. Among those 50% had consulted a medical doctor at least once before regarding their hormone use and only 27.5% had established their current hormone dose with a medical doctor.

Respondents showed patterns of high sexual activity. 59.1% reported 20 or more lifetime sex partners. 63.5% had had at least one casual sex partner and 31.8% at least one commercial sex partner during the 6 months prior to the survey. 57.1% had bought or sold sex ever before. Unprotected sex with different partner types was frequent - especially with regular partners. 78.7% reported to be most of the time the receptive partner during anal sex with men.

With regards to HIV testing, 40.9% reported to have tested for HIV before, and 51.9% of those reported that they had done the test on a voluntary basis.

Conclusions: MTF transgender people show high risk behaviors with regards to their general and sexual health and diverse barriers seem to exist for appropriate health care use. Medical supervision of cross-sex hormone treatment is insufficient, high sexual risk behavior common and HIV testing not frequently enough used. Prevention programs with focus on hormone intake and HIV/AIDS to increase knowledge and reduce risky behavior patterns are needed among this young and sexually active population. Access to VCT needs to be facilitated and counselors trained about particularities of gender minorities.


Keywords:      male-to-female transgender, kathoey, cross-sex hormones , HIV, VCT,

health risk behaviors.




We are very grateful to the two key informants of this study - Narupon Kunbootsri and Pathompong Wongkong. In this context we want to express additional thanks to Trai Wongsisri who supported us very much during the time of the fieldwork.

In addition, we want to express our greatest appreciation to all the transgender persons who participated in this study and who took their time to answer the questionnaire.

Special thanks for their help to Sam Winter, Associate Professor at the University of Hong Kong,  Korakoch Singmuang, the coordinator of the transgender counseling center ‘Sisters’ in Pattaya and Johanna Luhmann for her valuable editorial comments.






Abstract                                                                                                                                     1

Acknowledgement                                                                                                                      2

Index                                                                                                                                          3

Table index                                                                                                                                 4                     

Chapter 1             Introduction                                                                                                    5    

     1.1.    Background                                                                                                                 5

     1.2.    Objectives of the study                                                                                                 7        

     1.3.    A note on terminology                                                                                                  7


Chapter 2         Research Methodology                                                                                      7   

     2.1. Study population and data collection                                                                               7

     2.2. Research tools                                                                                                                8

     2.3. Data analysis                                                                                                                  8


Chapter 3         Results                                                                                                               8

     3.1. Socio-demographic characteristics and sexual orientation                                                 8

     3.2. General health risk behaviors and gender confirming interventions                                   10           

     3.3. Cross-sex hormone intake                                                                                            11

     3.4. Sexual health risk behaviors                                                                                          12

     3.5. Health care seeking behavior and HIV testing experiences                                             15

     3.6. Knowledge on HIV transmission and availability of HIV/AIDS treatment                       15  


Chapter 4         Discussion                                                                                                       16

     4.1. Socio-demographic characteristics and sexual orientation                                              16

     4.2. Gender confirming interventions and cross-sex hormone use                                          17

     4.3. Risk behaviors for HIV infection: Sexual health and drug abuse                                      18

     4.4. HIV testing experiences and general health care seeking behavior                                  20




Chapter 5         Conclusion and recommendations                                                                     20

     5.1. Conclusion                                                                                                                   20

     5.2. Recommendations                                                                                                        21


Bibliography                                                                                                                             22



Table Index




Table 3.1. Socio-demographic profile and sexual orientation of respondents                                9

Table 3.2. Nicotine, alcohol and drug use among male-to-female transgender participants          10

Table 3.3. Gender confirming interventions among respondents                                                  11

Table 3.4. Cross-sex hormone intake of respondents: Administration, supervision and                12                                                         

                 knowledge of side effects

Table 3.5. Sexual activity and sexual role of kathoey respondents                                               13

Table 3.6. Sexual health risk behaviors with different partner types among respondents               14

                 who reported sexual experience

Table 3.7. HIV testing experiences of MTF transgender participants                                          15

Table 3.8. Knowledge of HIV/AIDS prevention and treatment                                                  16



Chapter 1



1.1. Background

Transgenderism is a phenomenon which seems to occur in most societies (1). Definitive data on the prevalence of male-to-female (MTF) and female-to-male (FTM) transgenderism are lacking and depend as well on the definition used. In Thailand almost exclusively male-to-female transgenderism can be observed, but its prevalence is not scientifically established. The best estimates range from around 0.1 to 0.5 per cent and it is widely acknowledged that open transgenderism is found more commonly in Thailand than in most parts of the world, especially in the western societies (1, 2).

Hence, Thai language knows a variety of terms to denote MTF transgender people and the most commonly used is kathoey. Other terms that are less often used include sao praphet song or phu-ying praphet song, meaning both ‘a second kind of women’ (1).

These ‘third sex’ people have been a distinct part of the country’s culture and tradition and their presence can be traced back at least several centuries (1). And, they have somehow attained a prominence unknown anywhere else (1, 2). On the other hand, MTF transgender persons in Thailand still face diverse forms of discrimination, especially in the employment sector (2, 3). In addition, same-sex unions or the legal change of sex are not recognized by Thai law.


Only very little scientific publications have addressed the importance of the health risk behaviors and health care seeking patterns of MTF transgender persons in Thailand for general concerns of public health.

Internationally, qualitative and quantitative research in the field of public health has found that MTF transgender persons face different discriminations and health risks with HIV/AIDS constituting an outstanding social and medical issue. Available research indicates that HIV prevalence of male-to-female transgender persons ranges from 86% among 22 drug using transgender sex workers who were attending a dependency unit in Rome, Italy (4) and  35% among a not-exclusively sex-working sample in San Francisco, USA (5) to 11 % in Tel Aviv, Israel (6).  Transgender sex-workers in Jakarta, Indonesia, showed a HIV prevalence as high as 22% (7).

More specifically, with regards to Thailand, specific epidemiological data on the HIV prevalence of the large MTF transgender subpopulation has not yet been generated. Similarly, no data on their HIV testing experiences has been collected so far.

A recent questionnaire based survey found a HIV prevalence of 17.3% among male who have sex with male (MSM) in Bangkok, Thailand (8). This study (8) does not explicitly distinguish the different groups of MSM in the context of Bangkok and thus, it is not clear if kathoey were included in the sample – and if to what extent.  These findings proved that the MSM subpopulation is an important group of the changing Thai HIV/AIDS epidemic (9). Beyrer et al. (10, 11) found in different studies that participants who engaged in sex with male partners reported frequently to have had kathoey sex partners. These men showed riskier sexual practices than men who had only sex with female partners. Thus, they conclude that ‘studies of HIV and other health concerns among kathoey are urgently needed to assess the prevention needs of these transgender men’ (11).

On the one hand the kathoey can epidemiologically be seen as a sub-population of male who have sex with male (MSM), on the other hand, they identify themselves as a group different to the self-identified gay or bisexual men (1). Hence, the kathoey have different cultural and social networks and lives, and they may engage in different health risks or need particular preventive efforts.

Therefore in this assessment we aimed to describe the different sexual health risk behaviors and the HIV testing histories in a exclusively MTF transgender subpopulation in Khon Kaen, Thailand.  


In addition, the different practices used for the gender confirming process, such as longstanding cross-sex hormonal treatment and surgical interventions, are additional risk factors for the health of transgender beings (6, 12).  With regards to Thailand it is known that kathoey make regular use of cross-sex hormones and that they have frequently undergone diverse gender confirming interventions (1, 13). More specific data on hormone treatment and general health risk behaviors are very limited.

This investigation aimed, therefore, to generate additional knowledge about the hormone administration and the frequency of medical supervision of these practices and to describe the frequency of general health risk behavior, such as smoking and alcohol and drug abuse - among a kathoey sample.



1.2. Objectives of the study

The main objective of this study was to identify the behavioral patterns of kathoey in Khon Kaen Province, Thailand, with regards to their general and sexual health and their health care seeking patterns. The place of study was chosen to investigate a not mainly sex-working transgender sample in the North-Eastern part of Thailand.


1.3. A note on terminology

Sometimes, the term kathoey is used in Thailand to denote effeminate males as well as transgender people. In this work kathoey is used exclusively to denote MTF transgender persons. We are well aware that many MTF transgender people in Thailand reject the use of the term kathoey and prefer to identify differently. We do not want to insult anybody by its use in this study. Clearly, everybody should identify the way he or she wants. The term is used here  because of its consistent use in different scientific disciplines.


Chapter 2

Research Methodology


This research is based on a quantitative, descriptive survey conducted in Khon Kaen Province, Thailand between June and August 2006.


2.1. Study population and data collection

The study population was the MTF transgender persons who were living in Khon Kaen Province at the time of the study and who were aged 18 years or older and spoke and red fluently Thai.

A sample of MTF transgender persons was selected by the chain referral method of snowball sampling (14). Snowball sampling is commonly used in the study of hidden populations such as drug users, commercial sex workers or transgender persons (14, 15).  It was defined beforehand that every participant could only refer a maximum number of 4 peers to the overall sample in order to limit the problem that people who have large networks may name more people than people with smaller networks.

Two transgender kathoey – living in Khon Kaen - were chosen as ‘first seeds’ or ‘index participants’ (wave 0 in snowball sampling). Before the data collection, they have again been introduced to the purpose of the study and the sampling methodology.

These two key informants identified three and four transgender peers respectively to participate in the survey. Those then handed the questionnaire over to a maximum of 4 peers (wave 2) who then again were asked if they could identify further MTF transgender persons for the survey. In total 70 kathoey filled in the self-administered questionnaire. The network of key-informant A traced 45 participants for the study and the network of key-informant B traced 25 participants.


2.2. Research tools

Data was collected by a self-administered questionnaire containing closed questions.

The Thai version of the questionnaire was pre-tested among 12 kathoey. The final version of the questionnaire contained 56 closed questions.


2.3. Data analysis

Proportion was used to describe the categorical variables of the socio-demographic profile, the health risk behaviors, health care seeking patterns and knowledge of the respondents. Mean (standard deviation) was used to describe age and age of starting cross-sex hormonal intake. The data generated by the questionnaires was coded and entered in Microsoft Office Excel (2003). The data was imported for analysis to the EPI-Info Software (Version 3.3.2).


Chapter 3



Out of the 70 questionnaires, 3 were excluded from the analysis as two of the respondents self-identified as “gay” and “gay-queen” and therefore didn’t meet the inclusion criteria. The other questionnaire was excluded because the answers were very contradictory and provided invalid information.1

According to the logic and the order of the questions, participants had to skip certain items. Moreover, sometimes the given answers were invalid and couldn’t be included in the data analysis. Therefore the total number of respondents to every particular question varies and is highlighted always in brackets behind the name of the variable in the different tables.


3.1. Socio-demographic characteristics and sexual orientation

Table 3.1. shows the basic socio-demographic attributes of 67 male-to-female transgender persons in Khon Kaen Province, Thailand. 

Table 3.1.  Socio-demographic profile and sexual orientation of respondents




Age group (N=66)


  • £ 20                                                                                 
  • 21-30    
  • 31-40    

Means (SD)






26.3 (5.6)






Highest educational level achieved (N=67)


  • Primary education or less        

·         Secondary education (Grade 7-9)     

  • High School (Grade 10-12)
  • Vocational school                          
  • Bachelor degree or higher   















Current occupation (N=64) ¹


  • Employee in private sector or family business
  • Self-employed       
  • Employee in public sector        
  • Student                                      
  • Unemployed                              













9.4                                4.7

Health insurance (N=67)²


  • 30-Baht Scheme                                  
  • Social Security Scheme
  • Civil Servant Medical Benefit Scheme                                  
  • Private Insurance
  • No health insurance                 












7.5                                          14.9


Time lived in Khon Kaen Province (N=67)


  • Less than 6 months                         
  • Between 6 months and 2 years        
  • More than 2 years                                                 











Self-Identification (N=67)


  • Sao-praphet-song  [‘Second kind of women’]   
  • Kathoey                     
  • Women                        











Sexual orientation (N=67)


  • Feel most attracted to men                        
  • Others³                                                                









¹ One respondent answered to be ‘self-employed’ and ‘student’. The answer was classified as belonging to the item self-employed’.

² Respondents were able to choose more than one answer in this question. A total of 14 respondents (20.9%) indicated to have a combination of 2 or more insurances at the same time.

³ 2 of the 5 respondents felt most attracted to other transgender kathoey and 3 felt attracted, both, to men and women. No respondent indicated to feel most attracted to women.



Their age ranged from 18 to 39 years around an average of 26.3 years (SD=5.6). The study population showed a quite high level of education. In total, 70.1 % had achieved more than secondary school as their highest educational level and even 28.4% had finished at least a bachelor degree. With regards to occupation, most of the respondents were employee in the private sector (48.4%) or were self-employed (23.4%). 9 respondents (14.1 %) were employee in the public sector.

Participants were asked as well which word or term would best describe their self-identification with regards to their gender. The majority of MTF transgender respondents (55.2%) answered to self-identify as sao praphet song, meaning literally ‘ a second kind of women’, whereas only 35.8% preferred the most commonly used term kathoey for their gender identity. 6 persons (9.0%) thought of themselves as being a women.  With regards to their sexual orientation the vast majority (92.5%) of the study population felt most attracted to men.


3.2. General health risk behaviors and gender confirming interventions

Respondents showed generally risky behaviors with regards to abuse of nicotine, alcohol and drugs. Details are given in table 3.2.


Table 3.2.Nicotine, alcohol and drug use among male-to-female transgender   





Smoking cigarettes (N=67)



Alcohol consumption (last 4weeks) (N=67)


  • never or less than once a week
  • once or twice a week
  • more than 3 times a week











Ever consumed illicit drugs (N=63)                   



Type of drugs ever used among kathoey who consumed illicit drugs before (N=30)¹


  • Yabaa²
  • Mariuhana
  • Ecstasy ³
  • Cocaine
  • Heroin

















Ever injected illicit drugs (N=67)



¹ Respondents were able to choose more than one answer in this question.

² Name used in Thailand for amphetamines that are most commonly taken as  tablets or inhaled after being lit on a foil.

³ Equivalent to MDMA (3,4-methylenedioxymethamphetamine)


25 participants (37.3%) were smokers and almost half of the respondents had made use of illicit drugs at least once before. Those had experienced most commonly the use of Yabaa (Amphetamines) and Marihuana.  Only one of the 67 transgender persons had injected illicit drugs before.


Table 3.3. shows the detailed findings with regards to gender confirming interventions. Almost half of the sample (46.3%) had at least had one silicone injection before and 4  participants (6.1%) had already undergone full sex reassignment surgery (SRS).  Among those who have not yet undergone SRS, 40.3% answered that they would like to have a full sex change and 41.9% were not decided  yet.


Table 3.3. Gender confirming interventions among respondents




Silicone injections ever (N=67)



Breast implants ever (N=67)



Sex reassignment surgery ever (N=66)



Willing sex reassignment surgery  in the future (N=62)


  • No
  • Yes
  • Not sure













3.3. Cross-sex hormone intake

The vast majority (85.1%) of kathoey had used cross-sex hormonal drugs before and had started the treatment at a mean age of 16.4 (SD=2.96) years. At the time of the investigation 79.1% were taking hormones – as shown in detail in table 3.4.

Most of them (50.9%) were only taking hormones orally and 43.4% were using hormone injections contemporarily with the tablets. More than 95% of the participants reported that they had purchased their hormone tablets and injections in pharmacies or drugstores the last time they bought them. Only one respondent had bought their last hormones in the street.

In contrast, only around a fourth had had their last hormone injections done by a medical doctor. Although 92.5% knew that the intake of cross-sex hormones can cause side effects, only half of the participants had discussed their hormonal treatment with a medical doctor ever before and almost a third (31.3%) had decided their current hormone dose without consulting anybody with a medical background.


Table 3.4. Cross-sex hormone intake of respondents: Administration, supervision and knowledge of side effects




Hormone intake ever (N=67)



Age of starting cross-sex hormonal treatment (N=57)

Mean (SD)


16.40 (2.96)

Hormone intake at the time of survey (N=67)



Kind of cross-sex hormonal treatment of respondents currently taking hormones (N=53)


  • Oral hormone treatment only
  • Hormone injections and hormone tablets
  • Hormone injections only















Persons who administered hormone injection to respondents the last time (N=25)

  • Medical doctor
  • Nurse
  • Staff at private clinic
  • Pharmacist at pharmacy















Ever discussed hormone treatment with a medical doctor (N=52)





Discussed last hormone dose with… (N=51)


  • Medical doctor
  • Health personal other than medical doctor
  • Friend or family member without medical background
  • Dose was not discussed with anybody













Knowledge of side effects of cross-sex hormones (N=53)





3.4. Sexual health risk behaviors

Except three persons, all participants of the sample had had penetrative sexual intercourse before and 78.7% reported to be almost exclusively the receptive partner in anal intercourse with men (see table 3.5).

Participants were asked, furthermore, to estimate the total number of partners with whom they had penetrative sexual intercourse before.  41 respondents answered to this item by giving a numeric estimate. These estimates ranged from a number of 2 to 1000 lifetime sex partners. When analyzing the 44 answers that could be grouped, 59.1%  had had penetrative sexual intercourse with 20 persons or more.




Table 3.5.Sexual activity and sexual role of kathoey respondents




Ever had penetrative sexual intercourse (N=67)



Sexual role in anal intercourse with men (N=61)


  • Most of the time receptive partner
  • Most of the time insertive partner
  • Mixed sexual role











Number of sexual lifetime partners (N=44)¹


  • < 20 persons
  • 20 - 99 persons
  • ≥ 100











¹ Only 41participants answered to this question with a definitive numeric estimate. 10 kathoey didn’t respond at all to this item and a total of 13 respondents gave answeres such as ‘many, many’ or ‘uncountable or ‘more than 20’or others. The two answers reporting ‘more than 20’ sex partners were grouped in the second cluster and the response ‘more than 200’ was logically grouped in the third cluster for data analysis.



The participants were asked as well about their sexual risk behaviors with different types of sexual partners. Details of the findings are given in table 3.6. The definition of the different partner types was done carefully and with regards to the cultural context. They are outlined underneath table 3.6.

Among the respondents with sexual experience 57.1% had sold or bought sex in exchange for money or other goods before and almost a third (31.8%) had had at least one commercial sex partner during the 6 months prior to the investigation. 40 respondents (63.5%) reported to have had penetrative sexual intercourse with at least one casual sex partner during the same period of time.

Regarding safe-sex practices with these different partner types the findings show that three quarters of the particular respondents have had unprotected sexual intercourse with their regular partners and more than half of them with their commercial (57.1%) and casual (55%) partners in the last 6 months.


Table 3.6. Sexual health risk behaviors with different partner types among respondents who reported sexual experience




Regular partners






Regular partner(s) during the 6 months prior to survey (N=63)


  • No regular partner in the last 6 months    
  • Currently having a regular partner
  • No current regular partner, but had regular partner(s) during 6 months prior to study











Had sex with regular partner(s) during 6 months prior to survey (N=41)                       





Frequency of condom use with current or most recent regular partner (N=36)

  • Never
  • Sometimes
  • Almost every time
  • Always















Commercial sex partners






Commercial sex ever (N=63)



Commercial sex (last 6 months) (N=63)



Frequency of condom use with commercial sex partners (last 6 months) (N=21)


  • Never
  • Sometimes
  • Almost every time
  • Always















Casual sex partners






Sexual intercourse with at least one casual partner (last 6 months) (N=63)





Frequency of condom use with casual sex partner(s) (N=40)


  • Never
  • Sometimes
  • Almost every time
  • Always













¹ Regular partners were defined as ’somebody you feel an emotional bond with, such as feelings of love, and you care about a lot’.

² Commercial sex partners were defined as those ’with whom you bought or sold sex in exchange for money or other goods, such as jewelry, clothes or drugs’.

³ Casual partners were defined as those with whom ’you have no stable relationship and you are not in love with and with whom you did not have sex in exchange for money or other goods’.




3.5. Health care seeking behavior and HIV testing experiences

With regards to their health care seeking behaviors 37.3% of the participants have been to a health care facility during the 6 months prior to the study. Out of them 72% had visited a public facility (including primary health care centre) and the same amount of respondents had consulted a medical doctor at their last visit.

As to HIV testing, people were asked if they thought ‘that it was possible to make a confidential HIV test’. Almost three quarters (74.6%) did think this existed and 19.4% were not really sure. Additionally, 27 participants (40.9%) had tested for HIV before and out of these around the half (48.1%) reported that the last test was required. Almost all of them (92.6%) had obtained their test result. Details are shown in table 3.7.

Among the respondents who had tested before 59.3% thought that the testing facilities needed to be improved. The most important improvements suggested by these 16 participants were that the staff ‘should be more knowledgeable’ (43.7%), ‘the provision of knowledge regarding HIV prevention should be improved’ (37.5%) and that stigmatization should be decreased (31.2%).


Table 3.7. HIV testing experiences of MTF transgender participants




Knowing about VCT (N=67)


  • No
  • Yes
  • Not sure











Ever tested for HIV (N=66)



Voluntary vs. required (N=27)


  • Voluntary

·         Required 









Test result obtained (N=27)



Place of last test (N=27)


  • Public hospital
  • Private hospital/Clinic
  • Other











Improvement of  testing facilities needed (N=27)




3.6. Knowledge on HIV transmission and availability of HIV/AIDS treatment

Participants were asked two questions with regards to their knowledge about HIV transmission and one question concerning the treatment availability in Thailand. Table 3.8. shows the details of the findings.

More than two thirds thought that ‘avoiding sexual intercourse’ (67.2%) and that ‘using a condom every time during sexual intercourse’ (70.1%) protects against HIV infection in response to the respective question (table 3.8). More than half of the participants (56.7%) identified both, consistent condom use and avoiding sexual intercourse, as methods of reducing the risk of contracting HIV. Only 32.8% knew that HIV/AIDS can be treated in Thailand at present.


Table 3.8. Knowledge of HIV/AIDS prevention and treatment (N=67)




Knowing that avoiding sexual intercourse protects against HIV infection


  • Didn’t know
  • Knew
  • Not sure











Knowing that using condom every  time in sexual intercourse protects against HIV infection


  • Didn’t know
  • Knew
  • Not sure













Knowing that HIV/Aids can be currently treated in Thailand


  • Didn’t know
  • Knew
  • Not sure












 Chapter 4



In this part the results of our study are discussed and compared with findings of international and Asian research on the health related issues of MTF transgenderism.


4.1. Socio-demographic characteristics and sexual orientation

The sample of MTF transgender persons of this survey showed a rather high level of education and more than 70% of the respondents reported to have achieved more than secondary education. This is in parts caused by the sampling methodology and the fact that the two index persons for sampling were from a high educational background. With regards to sexual orientation Winter (13) found that 97.8% of kathoey participants in his sample reported to feel most attracted to men. This is consistent with the findings of our survey in which 92.5% reported the same.


4.2. Gender confirming interventions and cross-sex hormone use

In the same survey Winter (13) reports higher proportions of respondents who had already undergone silicone therapy (62.1% against 46.3% in our research), breast enlargement (39.5% against 22.4% in our research) and full sex reassignment surgery (27.7% against 6.1% in our research) than in our sample. This may be mostly due to differences in the sampling procedure of the surveys. Winter used targeted sampling and katheoy were approached at their place of work or at surgery clinics (13). It indicates that the group of transgender participants in our study consists in parts of persons who are less far in their gender transition histories. A lower proportion of people who underwent gender confirming therapy - especially expensive full SRS - may well be in parts due to the rather lower economical status of the people living in the North-East of Thailand in comparison with the people from the Central and Southern regions of Thailand. The findings remain controversial, especially regarding SRS and other authors report far lower proportions of  fully transsexual individuals among Thai kathoey than Winter (13). The proportion of respondents who had already undergone SRS (6.9%), for example, among  43 kathoey from different towns in Thailand researched by Totman (1), is very consistent with our own findings (6. 1%). Totman (1) used as well the networks of different key informants for his sampling procedure.

With regards to the considerable proportion of kathoey getting silicone injections and the high potential of abuse of silicone as well as the danger of considerable side-effects (16), further investigation of the pattern of silicone use among Thai katheoy should be conducted to develop preventive strategies. It would be particularly interesting to find out if silicone injections are partly done by non-professionals.


Our data confirm Winter’s (13) findings that a vast majority (93.8% against 85.1% in our assessment) are taking cross-sex hormonal treatment at some point in their lives and that they generally start at a quite early age around a mean of circa 16 years (16.3 against 16.4 years in our assessment). In comparison to international research, the proportion of MTF transgender persons who took hormones at the time of the investigation (79.1% in our survey) was slightly higher than among the 392 MTF transgender persons researched in San Francisco (73%) (6), or among 40 transgender prostitutes in the Netherlands (65%) (17).

Additionally, we found that a large fraction of our respondents were taking their hormones without or under minimal medical supervision. It seems of considerable concern that only 24% of the MTF transgender persons had had their last hormone injections administered by a medical doctor. But it is even more alarming that only half of the participants had discussed their hormone treatment with a medical doctor before and only 27.5% had established their current hormone dose together with a medical doctor.

Given the considerable risks of longstanding cross-sex hormone intake and the important side effects, this should be regarded as public health problem, especially as kathoey - most possibly - take high dosages of hormones to achieve fast changes in their gender transition process, as reported in the Western world (18). As smoking is most probably a synergistic risk for persons that are constantly taking female sex steroids this would be an important point that could be addressed in preventive efforts (18). This seems even more important, given that the proportion of smokers in our sample was higher (37.3%) than the national smoking prevalence of 19.5% of men and women aged 15 years or older - as reported by the National Statistical Office in the year 2004 (19). Another central point could be general introduction of trans-dermal estrogens for MTF transgender persons over 40 years of age (18).


4.3. Risk behaviors for HIV infection: Sexual health and drug abuse

We found additionally patterns of sexual risk behaviors that are known risk factors for HIV infection, such as high sexual activity, commercial sex and unprotected sexual intercourse. Among the respondents, 59.1% reported to have had 20 or more lifetime sex partners. Moreover, among those participants with sexual experience, 63.5% had had penetrative sexual intercourse with at least one casual sex partner and almost a third (31.8%) with at least one commercial sex partner during the 6 months prior to the investigation. 57.1% had bought or sold sex in their life before (see table 4.5. and table 4.6.). This is in line with a reported high frequency (80%) of sex work among MTF transgender persons in the USA (6). The findings underline as well the suggestions from different sources of the social sciences regarding the issues of sexual activity and sex-work among kathoey in Thailand. 

Regarding the frequency of safe-sex practices, inconsistent condom use was frequently reported. MTF transgender persons were less likely to use condoms consistently with their regular (25%) partners than with their commercial (42.9%) and casual sex partners (45%). This tendency among MTF transgender persons has been reported for Thailand (20) and the western societies (6, 21). On the other hand, the findings – and especially the frequency of unprotected sex with commercial sex partners - are inconsistent with past research. In San Francisco 26 % of the MTF transgender participants had unprotected receptive anal intercourse with casual partners and only 12% with commercial sex partners during the 30 days prior to the investigation (21). Similarly in qualitative investigations in Pattaya, Thailand (3), high proportions of sex-working transgender respondents reported consistent condom use with commercial sex partners. The general MSM population in Bangkok as well showed rather high levels of protective behavior with casual partners (79.1%) (7). 

When we analyzed the sexual risk behaviors of the 12 kathoey who have had all three different partner types during the 6 months prior to our assessment, 66.7% of them were found to have had unprotected sexual intercourse with their regular partners and 41.7% with both, their commercial and casual partners. This shows that these sexually most active respondents showed more protective behavior than the overall sample, but that the sexual risk behavior with casual and commercial partners was – as in the overall sample – very similar.

These differences – in comparison with other studies -may be in parts due to the fact that the kathoey of our study have to a great extent most probably not been subject of targeted preventive efforts and therefore showed more frequent risk behaviors than for example in the USA, Pattaya or Bangkok where targeted prevention exists – at least to a certain extent.  This point is supported by the fact that a rather low proportion of our sample (56.7%) was able to identify both, consistent condom use and avoiding sexual intercourse, as methods of reducing the risk of contracting HIV. Finally, the findings could be seen as being in line with the tendency that a lower proportion of men - than some years ago - were found to use condoms consistently with their commercial sex partners in Thailand (9). 

As with past research (6), we found that male-to-female transgender persons were much more likely to engage in receptive anal sex rather than insertive anal sex. This is of great epidemiological importance as the risk of HIV sero-conversion is much higher for the receptive anal partner than for the insertive partner in unprotected sexual intercourse among men (22).

More specifically, kathoey seem to have very rarely sex with women and they have mostly sexual intercourse with men who identify as heterosexual men and who are seen as such by their kathoey partners (13). These men were found to engage in riskier sexual behavior than men who have only had female sex partners (10, 11). Therefore kathoey may be an important epidemiological bridge between self-identified heterosexual men and their female sex partners or even spouses.

Finally, only one respondent of our sample reported to have ever injected illicit drugs. Thus, at least in our sample injection of non-hormonal drugs did not seem to be an important contributing risk factor for HIV infection. This low proportion in our sample does not seem to be due to an underreporting, as a rather high number (47.6%) reported that they had used illicit drugs before. The most commonly used drugs among this group of kathoey were Yabaa and Marihuana. This is consistent with reports that identify the use of Amphetamines and Marihuana generally as most common practice in the North-East of Thailand where a comparatively low prevalence of heroin and opium abuse is reported (23). In this context it is important to emphasize, that the rather common abuse of alcohol and illicit drugs in our sample may well contribute to the high frequency of  risky sexual behaviors.


4.4. HIV testing experiences and general health care seeking behavior

Despite the risky sexual practices among the sample of our study and a rather good knowledge of the existence of VCT, only 40.9% had tested their blood for HIV infection at least once before. Most of them had done so in public facilities and obtaining the result was not a problem in our sample. This proportion is similar to the one recently reported among MSM in Bangkok where 43.8% had tested before (8). It is a bit lower than among 19-35 year old adults living in peri-urban communities in Chiang Mai, Northern Thailand where 47% had ever done a HIV test before (24). With regards to the high frequency of sexual risk behavior and the fact that only around half of the tests had been done on a voluntary basis, our findings suggest that still a lot of barriers for accessing VCT exist for the transgender population. The preliminary findings among the 16 respondents who thought that the facilities where they had tested the last time needed to be improved, outlined that the most important issues for improvement were the knowledge of the health staff (43.7%). This is consistent with Kammerer’s (25)  argument that transgender people may have difficulties in accessing HIV services as due in part to the lack of service providers that are knowledgeable about transgender issues.



5. Conclusion and Recommendations


5.1. Conclusion

This quantitative, descriptive survey among 67 MTF transgender katheoy in Khon Kaen Province, Thailand, is to our knowledge one of the very first studies with a focus on different health related issues of this gender minority. The study used a non-probability sampling methodology and hence, the results and findings are not representative for all kathoey in Khon Kaen Province, the North-East of Thailand or the whole country. Still, the assessment points out very clearly that the sample of kathoey shows frequent and diverse health risk behaviors and many barriers exist for appropriate health care use – especially, with regards to hormone use and HIV testing. Thus, the study emphasizes the importance for more attention regarding the public health of MTF transgender persons in Thailand.   


5.2 Recommendations

This survey shows the important need for the improvement of the medical supervision of the often very early starting, unsupervised hormonal therapies. Therefore, guidelines should be developed in order to train medical doctors with regards to cross-sex hormonal treatment of transgender persons. The kathoey themselves should be educated about the need of medical supervision of their treatments and doctors should consistently counsel them. Targeted peer-to-peer education on these issues could be combined with important messages on sexual health and HIV/AIDS.

Further research should assess the exact dosages of hormones which are commonly used among the MTF transgender people in Thailand. The barriers to consult medical doctors and their knowledge about treatment regimes, contraindications and side-effects should be researched additionally.


Moreover, the frequent sexual risk behaviors among this not mainly sex working kathoey sample shows, first of all, the great need for targeted prevention on issues of sexual health towards kathoey. In addition, it points out the need for epidemiological investigations of the HIV prevalence in this subpopulation.

It should be emphasized that targeted prevention regarding HIV/AIDS and sexual health towards a not mainly sex-working kathoey population should not only focus on the well documented inconsistent condom use practices with regular partners, but underline the importance of protective behaviors with all partner types. Messages should include as well the risks of high sexual activity, frequent partner changes and commercial sex and the risk for HIV infection associated with specific sexual practices, such as receptive anal sex.

The development of messages should take into consideration that these MTF transgender persons mix only little with the gay subculture, as the two groups have its own different social and historical derivation with different lifestyles and with different preventive needs.

The preventive efforts towards all gender minorities in Thailand need further and increased political commitment and resource allocation.

Very importantly, the frequent involvement of kathoey in commercial sex should be considered in the context of remaining employment discriminations towards transgender people in Thailand. Additionally, the social rejection and a lack of a legal framework of their stable relationships should be taken in consideration.  In the long term, the legalization of same-sex unions by Thai law or the legally recognized change of sex would most possibly provide a less discriminatory social framework for the healthier lives of Thai kathoey.

 Besides the need for targeted prevention, further research should focus on the assessment of the networks through which kathoey buy and sell sex and qualitative studies may further assess the barriers to condom use with different partner types.


It seems, finally, important to facilitate the access to VCT among the transgender subpopulation, given the rather low proportion of participants who tested for HIV before. The findings of our research point out the need for training of  the staff of the VCT facilities. Capacity building should focus on the distinct needs of transgender persons and other sexual minorities in order to facilitate access for HIV testing and reduce the fear of stigmatization. Voluntary HIV testing and counseling (VCT) is last but not least one of the most important points for preventive messages through the assessment of individual risk profile. It is also an entering point for treatment and care of HIV/AIDS.




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