Retracing the path of 'Tangerine Clinic' and pushing for benefits for transgender

This text discusses a significant advancement in Thailand, where the National Health Security Office (NHSO), responsible for the health of over 47 million people, is considering adding 'health services for gender confirmation or gender transition' as a benefit. The aim is to provide safe and cost-free access to services for those in need, eliminating the financial burden, including monthly expenses for hormone therapy, which could be as high as 1,000 Baht.

While this development didn't happen overnight, it is the result of prolonged and continuous efforts. The driving force behind this initiative is the 'Thai Transgender Health Clinic,' the first comprehensive community health clinic for transgender individuals in Thailand. The discussion about these benefits has progressed to the evaluation phase with the Health Intervention and Technology Assessment Program (HITAP) since the end of 2023.

The clinic's journey began in 2015, with the intention of making health services for gender confirmation or gender transition a universally accessible benefit. Now, with the government showing positive inclinations, it marks a significant step forward.

"The Coverage" invites Krittimas Samittipol, Head of the Transgender Health Clinic at the Institute for HIV Research and Innovation (IHRI), to reflect on the efforts and hopes that have led to making health services for gender confirmation or gender transition more accessible for everyone.

 

 

Offer all the health services that should be available for 'transgender' as a benefit.

It is well known that 'HITAP' is one of the organizations collaborating with the NHSO in considering benefits for inclusion in the national health insurance system. This collaboration opens opportunities for people from all sectors, from the general public to experts, to propose necessary health service packages.

The Transgender Health Clinic has compiled service data since its establishment in 2015, presenting health service packages for transgender individuals who 'have never had' and 'should have' as benefits. Over 10 service topics from the social sector were proposed at the end of 2023.

During the presentation, questions were answered by qualified experts based on service experience and collected data. After presenting all topics for consideration, the 'Health Services for Transgender Individuals' was voted as one of the top 5 most important topics by the presenters.

HITAP further studied the proposal, considering aspects such as cost-effectiveness, the number of service recipients, necessity, and service locations. Some additional research was identified as necessary and forwarded to the Health Systems Research Institute (HSRI) for further investigation.

Simultaneously, the IHRI's Transgender Health Clinic collaborated with the Siriraj Health Policy unit at the Faculty of Medicine, Siriraj Hospital, Mahidol University, to conduct policy-oriented health research, securing funding from HSRI.

The research process took some time, and during a community meeting, an invitation letter was sent to Mr. Anutin Charnvirakul, the Minister of Public Health at that time, to follow up on the matter. Fortunately, they had the opportunity to meet with him and Dr. Jedtossadawut Ariyathachai, the Secretary-General of the NHSO, which marked a crucial moment in the research process.

Reflecting on that day, the narrator mentioned that it was the 'most worthwhile' day, as they met key figures involved in both policies. The response received from the officials provided clarity on how to proceed after the presentation of benefit topics, addressing the uncertainties during the review process.

'Guideline' health services for transgender people 'The first Thai edition'

Krittimas narrates that before presenting to HITAP, there was one thing that could answer all questions and demonstrate the real commitment to driving the issue forward. It was the creation of the 'Guidelines for Health Services for Transgender People in Thailand.' This guide was developed in collaboration with experts and professionals involved in transgender health at Chulalongkorn University, bringing together multidisciplinary medical expertise covering both children and adults from medical schools and various organizations. The collaboration involved multiple processes, culminating in the creation of the first comprehensive health service guide for transgender individuals in Thailand in 2023.

"We see working with Chulalongkorn University as the most crucial starting point during that time. The advantage was that our organization had a working foundation in HIV/AIDS alongside Chulalongkorn University. Additionally, Chulalongkorn Hospital had been providing gender confirmation surgeries, likely one of the first in Thailand. Chulalongkorn University had the experience and existing knowledge. The cost for surgical services was very reasonable, but the accessibility for the general public was very limited."

During that time, she and the team worked hard because opening a specialized community clinic like this was unprecedented. Even though there were some existing networks, they still faced operational challenges, including referrals, consultations with specialized professionals who needed to have a 'contextual understanding of gender,' especially psychiatrists for both children and adults, as well as surgeons or endocrinologists, etc.

"We and the team worked closely with all stakeholders to create this guide, developed to be applicable in the context of Thailand, covering services for both children and adults. In the end, this guide has become a model for many other countries, such as the Philippines, Vietnam, Sri Lanka, Myanmar, etc. Even though global guidelines exist, there has never been a Thai or regional guide."

"This guide provided us with answers when presenting benefit packages to HITAP, allowing us to address questions and issues that had never been tackled before. It also helps us respond to policies from the government sector that may not fully understand our perspectives. It answers the question that health services for gender confirmation or gender transition are not just about beauty but are intricately connected to health."

 

 

More than beauty is 'safety - health necessity'

Throughout the persistent advocacy, it is inevitable to encounter questions from some who perceive that providing services for gender confirmation or gender transition is still about 'beauty.' Krittimas explains that the effects of hormone usage do not directly make someone beautiful or handsome. It doesn't give someone a prominent nose, larger eyes, a slender face, or a proportionate physique according to societal beauty standards, which may vary in each community. However, hormones play a role in complementing the 'gender identity' of the individual, making it more complete.

"Hormones may induce softness, breast development, changes in skin complexion, or make someone appear more feminine or masculine. However, ultimately, beauty depends on the individual's original physical foundation, which varies, and the definition of beauty differs for each person or societal preference."

"Not everyone in the transgender community may want to use hormones or undergo surgery to confirm their gender identity. Still, accessing hormones is a health necessity for those who require it, and the lack of access, starting from counseling or proper guidance on medication use, poses risks from self-administered medications. We have no way of knowing how much knowledge each individual has about medication or hormones."

Everything is already there, all that remains is to 'expand' it to make it accessible to everyone who wants it.

Krittimas reveals that, indeed, hormone replacement therapy is already included in the existing benefits package. However, it is specifically stated for services in the category of hormone replacement therapy for transgender individuals, such as transgender women in their golden years and children who may have hormonal issues related to physical development.

"Especially for individuals who have undergone gender confirmation surgery, the primary source of hormones in the body disappears, and hormone usage may still be necessary; otherwise, it could affect health. For instance, transgender women who have had surgery may face similar issues to cisgender women in their menopausal years, where the body no longer produces hormones."

"Everything is already available, even where to get the examinations, in which department. Hormone level checks are already part of the existing benefits. Therefore, there's almost nothing new to be done, except for expanding services to make them accessible to transgender individuals."

Finally, investing in this matter doesn't require a substantial amount of money because there are service units already relatively well-prepared. It simply involves expanding the scope of services and, in terms of knowledge, there are guidelines for services relatively ready for additional staff training. Investing in preventive health aspects may save costs compared to treatment expenses, which could be higher. However, what cannot be assessed is the value of the health and quality of life of the population.

 

 

5 proposals that you would like to include 'Benefits'

After receiving signals from the National Health Security Office (NHSO) regarding the inclusion of health services for individuals with diverse gender identities, including transgender individuals, in the benefits package two weeks ago, the NHSO, led by Dr. Jitdet, and related executives, urgently contacted IHRI to set up a meeting table to discuss 'what health services should be included as benefits' in the gold card system.

Krittimas stated that information had been gathered from community representatives and organizations working on relevant issues. Five main service topics were proposed, including:

1. Counseling for individuals with diverse gender identities, providing services to the public seeking assistance and counseling for those starting the process of gender confirmation or transitioning.
2. Health check-ups or laboratory tests related to health.
3. Medications for gender confirmation or transitioning, covering both children and adults.
4. Gender confirmation surgeries.
5. Health services related to rights and laws, such as counseling in cases of gender-based violence, discrimination, affecting mental health.

As all of these are related to "health," impacting both physical and mental well-being, the discussion with NHSO this time has taken a somewhat positive direction. This is because Dr. Jitdet had information from our previous submission and had representatives from community, social organizations, and service providers from various medical schools, including the recently established ThaiPATH, to support. However, it is understood that the NHSO may need time to carefully examine budgetary and regulatory issues.

"If the policy side is on board, the barriers to accessing services will be easier to overcome, benefiting the public seeking services. We are ready to coordinate, prepare necessary information, answer questions, attend meetings, and even pause other tasks to proceed with this matter. We are committed to giving our full support."

I want to see health services for transgender people. It is part of the 'Primary' work.

Regarding the ultimate hope for the TransClinic at present, Krittimas expressed that it is to witness comprehensive healthcare services for transgender individuals, covering everything from counseling to gender confirmation surgeries, included as benefits. She also desires to see these services as "primary" services, allowing accessibility for everyone.

 

 

Data from previous years estimated that Thailand has over 300,000 transgender women alone, excluding transgender men and individuals with diverse gender identities. Currently, this number may have increased, and relying solely on specialized clinics or large hospitals might not be sufficient. Therefore, some basic services, such as counseling and health check-ups, should be available as primary care services, allowing the general public the most accessible entry point and a referral system for more complex cases to specialized units.

This aligns with the World Health Organization's (WHO) redefined understanding that individuals seeking gender-affirming care are not mental health patients, and gender confirmation services should be part of primary care to address issues of service inaccessibility. Achieving this would be a significant step toward the "deconstruction and reconstruction" of the healthcare system.

Furthermore, one significant reality is that the number of transgender patients at the TransClinic at Tangerine and community health clinics in its network currently exceeds 10,000. This raises the question of whether community clinics can achieve this, and if so, why can't the state?

"We may have healthcare services for transgender individuals available in various aspects in Bangkok. We are not worried because several services are already in place. However, in other areas outside of Bangkok, we want to ensure there is at least a basic level of service. This may need to be gradually implemented based on the context and readiness of each area."

"Thank you to the diverse gender community, civil society organizations, government agencies, and supportive individuals who play a crucial role in driving this issue forward. I would like to express my gratitude to everyone who may not be mentioned by name."

 

 

refer: The Coverage