Flak for gender-affirming hormone therapy move

Thailand's decision to provide free gender-affirming hormone therapy under its universal healthcare scheme has prompted questions about how the National Health Security Office (NHSO) should prioritise spending amid growing pressure on the public health system.

The programme, which covers around 20,000 transgender people at an estimated cost of 145 million baht annually, began distributing medicines through participating healthcare units nationwide on June 10.

It offers eight hormone-related drugs across four categories: oral and topical female hormones, injectable male hormones, oral androgen blockers, and central hormone-suppressing injections. Recipients also gain access to health screenings, mental health counselling, and laboratory tests monitoring hormone levels, liver and kidney function, and metabolic health.

For transgender communities and their allies, the policy marks a landmark victory after years of advocacy. Civil society groups, led by transgender networks, had long argued that equitable healthcare must address both physical and psychological wellbeing, a position the NHSO board endorsed when it approved the scheme last month.

Yet the timing has drawn scrutiny, particularly amid concerns over funding constraints affecting the universal healthcare scheme. State-owned hospitals across the country are operating under sustained financial pressure, prompting debate over how limited resources should be distributed across competing health needs.

Vaccines delayed

Senator Veerapun Suvannamai has emerged as one of the most vocal critics, saying NHSO decisions must reflect both transparency and public health priorities.

He pointed to a long-running campaign to include pneumococcal conjugate vaccine (PCV) under universal coverage, which would benefit more than 300,000 toddlers nationwide.

"We've spent over a decade fighting to include the vaccine, which would benefit more than 300,000 toddlers nationwide. Yet, the vaccine still hasn't been given to them. Meanwhile, with a much shorter path to the goal, nearly the same budget has been approved for a therapy that benefits just 20,000 people," he said.

The comparison has become central to criticism from those who argue that funding decisions should be guided by broader population impact and urgency.

Dr Veerapun said the World Health Organization no longer classifies gender incongruence as a mental disorder and questioned whether hormone therapy should therefore be prioritised within the universal healthcare scheme, given that transgender individuals already retain access to healthcare for other medical conditions.

"My question is the hormone therapy is really an urgent issue when a majority of people is still waiting for other basic medical treatment included into the universal healthcare scheme," he said.

Safety concerns

Beyond questions of priority, Dr Veerapun raised concerns about the safety profile of certain drugs included in the programme, particularly gonadotropin releasing hormone (GnRH) analogues.

These synthetic hormones act by mimicking or blocking natural gonadotropin-releasing hormone, preventing the pituitary gland from signalling the ovaries or testes to produce sex hormones.

They are currently approved for conditions such as precocious puberty, prostate cancer, and endometriosis.

He said there was insufficient evidence regarding their long-term use among transgender patients and warned of potential impacts on bone density, brain development, and the reproductive system, particularly in younger users.

"This is not the issue of sexual prejudice," he said. "But it is related with necessity and priority when we are facing with very limited resources. Next week, we will invite NHSO for further explanation toward the decision."

NHSO defends process

Dr Attaporn Limpanyalert, deputy secretary-general and spokesman for the NHSO, rejected suggestions the approval lacked rigour.

He said that the decision followed extensive discussion among committee members and expert working groups before being endorsed.

He said all concerns raised during the process were reviewed by specialist panels, which concluded that the programme represented a justified investment in public healthcare.

The scheme is now part of the universal healthcare system, although the NHSO has yet to publish detailed eligibility criteria. It has said applicants will undergo initial screening by healthcare professionals, including psychologists, before accessing treatment.

Advocates push back

Supporters of the policy have pushed back against criticism they said risks stigmatising minority groups.

Kittinun Daramadhaj, president of the Rainbow Sky Association of Thailand, said the debate should focus on equitable access to healthcare rather than budget constraints alone.

He warned that framing the discussion through prejudice risks portraying minorities who rely on public healthcare as a burden on society.

The wider debate ultimately reflects a structural challenge facing the health system. While there is broad agreement on the principle of equitable access to healthcare, disagreement persists over how limited public resources should be allocated between competing priorities.

As the NHSO moves forward with implementation, it faces continued scrutiny over both its decision-making process and the balance it seeks to strike between equity, urgency, and long-term public health impact.

Veerapun: Questions vaccine delay

Attaporn: 'Concerns were reviewed'

Kittinun: 'Focus on equitable access'