Free hormone therapy: The trans debate splitting Thailand

The decision to include transgender hormone therapy in Thailand’s universal healthcare scheme, coinciding with Pride Month, has sparked heated debate over state healthcare priorities, social biases, and public spending.

With the country’s universal healthcare or Gold Card scheme already struggling financially, critics are asking why the National Health Security Office (NHSO) was so quick to earmark roughly 145 million baht for medicines needed by gender-transitioning individuals.

“I understand that every Thai has the right to medical care, but is the NHSO financially strong enough to do this?” asked Dr Veerapun Suvannamai, vice chair of the Senate committee on public health.

He pointed out that many clinics under the scheme have shut down because of financial difficulties, while many community hospitals now lack even basic medications, not to mention much-needed drugs for cancer patients and dialysis for kidney patients.

“I want to emphasise that transitioning individuals are not facing life-threatening conditions,” the prominent doctor-turned-senator said.

However, his opposition to transgender therapy has sparked an outcry among advocates of the new policy – including Dr Nittaya Phanuphak, executive director of the Institute of HIV Research and Innovation (IHRI).

‘Unconstructive comparisons’

Dr Nittaya is concerned that treatments for different medical conditions are now competing for budget, such as transgender therapy versus kidney dialysis.

"In the public health sphere, patients have equal rights. Treatment is not prioritised based on whether they have a life-threatening condition or not,” the doctor said.

“Comparisons are endless and unconstructive. Should we prioritise the medical needs of young people over those of the elderly just because youngsters are more productive?”

In addition, she noted that healthcare budgets should not focus just on treatment, but also on prevention. Many transitioning Thais are putting their health at risk by buying oral or topical hormones over the counter or via unregulated online channels.

Nachale Boonyapisomparn, a transgender activist, said that these unmonitored medicines can cause chronic liver and kidney problems, which end up costing the NHSO a lot more to treat in the long term.

Dr Nittaya defended the NHSO’s policy, saying the decision to include gender-affirming hormone therapy in the universal healthcare scheme was backed by solid data.

Best Wongpairojkul, deputy secretary-general of the Thai Sang Thai Party, also backed the policy, noting that the World Health Organisation (WHO) has officially recognised “gender incongruence” as a medical condition.

In the latest update of its global medical blueprint, the WHO shifted gender affirmation out of the mental health chapter into a newly created chapter on sexual health.

Best pointed out that providing hormonal therapy for transgender individuals aligns with modern public health principles that focus on prevention as well as treatment.

“From this perspective, it is no different from deploying vaccines, screening for cancer, or providing routine health checks,” he said.

Nachale, who also chairs the National Health Assembly’s committee on public policies for transgender people’s wellbeing, argued that opposition to the policy is based on social bias.

She noted that the transgender population across Thailand currently stands at more than 300,000, yet access to safe hormone therapy is limited mainly to Bangkok and other big cities.

“Transgender people living in remote, rural areas would have no access to safe hormone therapy if it was not covered by the universal healthcare scheme,” Nachale said.

She added that expanding the scope of the universal healthcare scheme also opens the door to free medical care for other marginalised groups.

The bigger picture

Dr Anukul Thaithanan, an adviser to the Thailand Regional and General Hospital Society, countered that critics of the move are not necessarily motivated by anti-trans views. The controversy, he said, is not about whether people should be given access to free hormone therapy, but rather the timing of the policy.

Transgender hormone treatment was made available for all citizens under the universal healthcare scheme from June 10. The NHSO has allocated an annual budget of 145 million baht for hormone therapy and believes it can treat about 20,000 transgender people per year.

“The focus should be on prioritising what kind of medical services are available in the healthcare scheme,” Dr Anukul said. “Unfortunately, the NHSO has just looked at the data surrounding hormone therapy without considering the overall picture.”

He noted that the Budget Bureau recently called for a rigorous review of public spending because Thailand’s financial constraints have risen over the past few years.

Prominent neurosurgeon Dr Methee Wongsirisuwan insists that the NHSO board itself should be reviewed for what he described as its failure in setting priorities.

“It’s not just about earmarking 145 million baht [for transgender hormone therapy]. More funding will be needed for mandatory lab tests, follow-up treatment, and continuous, lifelong care. Plus, this policy has been approved at a time when many state hospitals are struggling financially,” he said in a Facebook post.

The NHSO’s defence

Dr Atthaporn Limpanyalert, NHSO deputy secretary-general, said the new policy had been widely debated and reviewed by relevant subcommittees before it was forwarded to the board.

“All available academic evidence, health economics, benefits, and impacts were closely studied before the policy was added to the board’s agenda,” he said.

He also urged critics to stop comparing hormone therapy to vaccination against pneumococcal disease. Shots that provide immunity against the invasive bacterial infection are currently only available in high-risk areas. The potentially fatal bacterial infection can lead to meningitis, blood sepsis, and severe pneumonia among infants and the elderly.

“Don’t compare the two, as this will only cause conflict among Thais,” Dr Atthaporn cautioned.

He added that the authorities are currently negotiating the price of pneumococcal vaccine with suppliers and need more time to figure out how best to cover the population within the available budget.

He said the NHSO board remains ready to review the hormone therapy policy if new, internationally recognised evidence suggests that it is neither appropriate nor cost-effective.