Overview

Thailand is often held up as proof that "trans people have always existed and been accepted". Its kathoey (males who live in a feminine role; see below) are highly visible, Bangkok is the world's best-known centre for sex-reassignment surgery, and Thai culture is often described as uniquely tolerant. The reality is more complicated and more interesting. Kathoey identity grew out of a strongly gendered, patriarchal society. It is explained through Buddhist ideas of karma, and it applies far more to males than to females. Thailand still does not allow anyone to change their legal sex. And much of its surgical industry serves foreigners rather than Thais.

This page looks at kathoey history and terminology, the Buddhist framing, the asymmetry between kathoey and masculine women (toms), the surgery and hormone economy, and Thailand's legal position. It is part of the third gender cultures section, alongside India's hijra, Iran and Pacific cultures.

What "kathoey" means

Kathoey (กะเทย) is a Thai word. According to the historian Peter Jackson, it originally referred to intersex people (Jackson 1997). It later became a very broad term for any male who broke male role expectations, including gay and effeminate men, and is now most often applied to males who live as women (Winter 2006). Jackson defines the modern term broadly to include "hermaphrodite persons as well as effeminate, cross-dressing, or transsexual males" (cited in Ng 2012).

The label is fluid. It can cover:

• feminine gay men who do not try to pass as women;
• males who cross-dress and take hormones but keep their genitals;
• males who have had full surgery and live entirely as women.

Several related terms exist. Phet thi sam means "third sex". Sao praphet song or phuying praphet song means "second kind of woman". In recent decades many have adopted the Western term "transgender woman". Self-description is shifting. A study of 195 Thai transgender women found that most called themselves simply phuying ("women"), a minority used "second kind of woman", and very few called themselves kathoey (Winter 2006). So it is not accurate to say that kathoey "don't claim to be women". The traditional third-category model and the newer Western "trans woman" model now exist side by side, sometimes uneasily. One trans woman on r/MtF describes the mix:

A lot of people do like to point at Thailand as some kind of trans paradise when it's actually a confusion of colliding paradigms most of the time. —ItsMeganNow, trans woman (MTF)

The English word "ladyboy" became widespread during the Vietnam War era, when Western soldiers took leave in Thailand. Some Thais find it offensive and others use it of themselves.

Buddhism and karma

More than 90% of Thais are Theravada Buddhists, and religion shapes how kathoey are understood. The Pali scriptures recognise four sex/gender types: male, female, ubhatobyanjanaka (roughly, intersex) and paṇḍaka (roughly, effeminate or "deficient" males). The Thai translation of the monastic code renders paṇḍaka as "a kathoey, a castrated man or eunuch" (Jackson, Thai Buddhist tradition). The monastic code bars paṇḍaka from ordination, and in Thai practice this has been applied to kathoey (Gender-diverse spirit mediums, 2025).

The common explanation is karma. Being born kathoey is often seen as the result of sexual misconduct in a past life, such as adultery or being a "heartbreaker". In this life the kathoey is thought to repay that debt, often through unrequited love. This framing has two sides:

• It reduces hostility. If a person did not choose their condition, there is nothing to punish. Thais are encouraged to show compassion and tolerance.
• It builds in inferiority. The kathoey is pitied as someone paying off past sins, not respected as an equal. A Thai film critic put it this way: "You're already seeing queer people as lower than you if you view them as someone with attached karma who must be punished for their past sins" (BK Magazine).

Peter Jackson's well-known phrase for Thai attitudes is "tolerant but unaccepting". Kathoey are visible and rarely attacked, but they are often laughed at, kept out of respectable jobs and treated as comic figures in the media (Ng 2012).

Kathoey do have one traditional route to respect: spirit mediumship. In northern Thailand, researchers estimate that more than half of spirit mediums are now gender-diverse males, most of them attracted to men. Mediumship gives them a spiritual status that ordinary social life often denies them (Gender-diverse spirit mediums, 2025).

The asymmetry: kathoey and toms

Thailand has an established, visible category for feminine males. It has no equivalent third-gender category for masculine females. Masculine women do exist and have their own label: tom (from "tomboy"). Their feminine partners are called dee (from "lady"). But toms are generally understood as a kind of lesbian or "female man", not as a separate third sex with its own history, religious meaning, pageants or surgical industry (Sinnott 1999).

Megan Sinnott's ethnography describes an interpreter in Bangkok translating "lesbians" as phu-chai, "men". In mainstream Thai thinking, a female who desires women is simply understood as masculine (Sinnott 2004). Toms have their own identity, but it is less institutionalised than kathoey identity. Medical transition among them is also much less common. Chokrungvaranont and colleagues reported that female-to-male surgery is "not common in Thailand even within the private sector". At Chulalongkorn University Hospital they recorded only three or four mastectomies a year and fewer than ten penile reconstructions in twenty years (Chokrungvaranont et al. 2014). A trans man living in Thailand describes the difference:

In country, trans women are definitely much more visible and familiar to the general public. The idea of a transmasculine or transman identity is a bit of a different story. —Some-Interaction8175, trans man (FTM)

Why the asymmetry exists

The most convincing explanation is patriarchy. In a male-dominated society, a man who gives up masculinity is seen as stepping down the hierarchy, which is disturbing and needs explaining. A woman who acts masculine is seen as reaching up. That is less threatening and easier to dismiss as a phase or a lesbian quirk. A separate kathoey category deals with the "problem" of the feminine male by placing him outside manhood altogether. Manhood stays intact, and the effeminate boy gets a defined, if lower, place.

Detransitioners who have looked at third-gender cultures often draw this conclusion:

Yes...many cultures and societies that are way too sexist/patriarchal/misogynistic to be able to conceive a GNC man or a GNC woman. That's why they made up those genders. —PM-me-darksecrets, desisted female

I used to think it was very progressive, but then I began realizing that these countries are both very patriarchal and conservative, but also very unequal. Gender roles are very strict. The "third gender" is not a sign of progressive attitudes, but conservative attitudes to gender. —Affectionate_Act7962, desisted male

This links to a recurring theme on this site: in some cultures, transition can work as a way out for same-sex-attracted males. A detransitioned man from the region puts it directly:

Like for example here in Philippines or Thailand, most transwomen are gay men (including me) who transitioned because of internalized homophobia due to being brainwashed by religion that Gay is bad and sinful and etc.. —Entire-Construction1, detrans male

This is one person's view, not a measured finding. But it fits what Blanchard's typology (a model that sorts male-to-female transition into two types by sexual orientation) predicts for androphilic males (attracted to men; Blanchard's "homosexual transsexuals", or HSTS) in societies where feminine gay men have few other accepted roles. See also internalised homophobia.

Pageants and the performance of femininity

Kathoey are most visible internationally through beauty pageants, such as Miss Tiffany's Universe in Pattaya, and cabaret shows. They are often presented as signs of Thai openness. But they reward a very narrow ideal: fair skin, slim bodies, delicate faces and convincing femininity, usually achieved with hormones, implants and facial surgery. What is celebrated is not gender non-conformity but successful imitation of a conventional feminine ideal.

This mirrors a central argument of the detrans perspective. A culture that "accepts" feminine males by reshaping them into women has not accepted gender non-conformity. It has turned non-conformity into a different kind of conformity. The alternative, a feminine man who stays a man, has less room in Thai society. See gender non-conformity without labels and gender stereotypes.

Hormones without prescriptions

In Thailand, cross-sex hormones are easy to buy over the counter, and young people often start them early and without supervision:

• In a 2024 study of transfeminine people in Chiang Mai, 86.7% had used hormones. The average starting age was 16.6. Over 91% got their hormones from pharmacies, and only 8.6% had a doctor's prescription. Using many different brands and stopping for six months or longer were both common (Exogenous hormone use in Chiang Mai, 2024).
• In an online survey of 256 Thai transfeminine youth aged 12–25, 88% reported having used hormones, many without prescriptions (Aungkawattanapong et al. 2024).

Here, social "acceptance" coexists with a largely unsupervised medical pathway that starts in adolescence. The long-term effects on fertility, bones and the cardiovascular system are not well tracked. For comparison, see DIY hormones and estrogen and testosterone blockers in males.

The surgical tourism industry

The first male-to-female sex-reassignment surgery in Thailand was performed at Chulalongkorn University Hospital in 1975. Over the following decades a private industry grew up, built on a few high-volume surgeons and low prices. A 2014 review by Thai surgeons found (Chokrungvaranont et al. 2014):

These numbers matter. Thailand's surgical reputation is mainly an export industry. In 2010–2012, 90% of patients were foreigners. They typically came for a few weeks, had surgery and then returned home, where follow-up was left to local doctors (Chokrungvaranont et al. 2014). A two-week follow-up for an operation that needs lifelong dilation and can have serious complications is a structural weakness. For people who later regret surgery or develop problems, the surgeon is on another continent. A detransitioned man describes a friend's experience:

He flew across the globe and went to one of the best surgeons in Thailand, yet it still prolapsed… He would constantly email the doctor and the doctor would gaslight him and say the result was perfect —Aware-Resist-8655, detrans male

This is a second-hand account and should be read as such. But the gap in follow-up it describes is what the 2014 review's figures suggest. Since 2009, the Medical Council of Thailand has required patients to be at least 20, or 18 with guardian consent, and to have assessments from two psychiatrists before surgery. These rules were introduced to standardise what had been a largely unregulated practice (Chokrungvaranont et al. 2014). See vaginoplasty and iatrogenic harm.

Legal status: no change of sex

Despite its reputation, Thailand does not allow anyone to change their legal sex, even after full surgery. The national ID card uses binary prefixes based on sex at birth (Outright International). This has practical consequences:

• Military conscription. All 21-year-old males must take part in the conscription lottery. For years, kathoey were exempted with a form (Sor Dor 43) recording a "permanent mental disorder", which employers could see. After a legal challenge (Samart Meecharoen v. Defence Minister), the military agreed in 2011 to stop labelling transgender draftees "permanently insane" (ICJ 2011).
• Prisons. Kathoey are held in male prisons, and former inmates describe being denied hormones while inside (UNDP 2019).
• Employment. Kathoey are concentrated in beauty, entertainment, retail and sex work. Discrimination in professional and government jobs is widely reported.

The Gender Equality Act 2015 prohibits discrimination against people with "a sexual expression different from that person's original sex". Rights groups have criticised its exemptions for education, religion and national security (Outright International).

The Marriage Equality Act came into force on 23 January 2025, making Thailand the first country in Southeast Asia to allow same-sex marriage. It uses gender-neutral terms for spouses but does not change anyone's legal sex. Transgender people still marry according to their birth sex (International Bar Association). Several draft gender recognition bills, some based on self-identification and some including an "X" option, have been put forward but not passed (Outright International).

What Thailand tells us

From a detransition perspective, Thailand offers several lessons.

1. Visibility is not the same as acceptance. Kathoey are tolerated, but often as objects of pity or comedy. Peter Jackson's "tolerant but unaccepting" still describes much of everyday life.
2. Third-gender categories depend on sex. The well-developed category is for males. Masculine females are treated as toms or lesbians. This asymmetry fits a patriarchal explanation better than an innate-identity one.
3. The categories absorb gay males. Many kathoey and Thai trans women are attracted to men, and some describe transition as a way out of anti-gay stigma.
4. Social role and medical transition are different things. For centuries kathoey existed without hormones or surgery. The medical pathway is recent, often unsupervised, and largely built around foreign customers.
5. Law and culture can diverge. Thailand is socially visible but legally binary. Its model is neither the Western "gender identity" model nor simple rejection.

Thailand is therefore weak evidence for the claim that trans identity is a timeless, universal fact that medicine simply recognises. It is better evidence that each culture creates its own scripts for people who do not fit its gender roles. Those scripts reflect that culture's sexism, religion and economics, and in Thailand's case a global surgery market.

Related pages

• Third gender cultures
• MVPFAFF and Pacific cultures
• Iran: surgery as an alternative to homosexuality
• Sex vs gender in law
• Surgery

References

• Jackson, P. A. (1999). Tolerant but unaccepting: The myth of a Thai "gay paradise". In P. A. Jackson & G. Sullivan (Eds.), Lady Boys, Tom Boys, Rent Boys. Cited via Ng (2012).
• Jackson, P. A. Male homosexuality and transgenderism in the Thai Buddhist tradition. source
• Ng, F. (2012). Kathoey: I'm not a boy, not yet a woman? Prized Writing, UC Davis. source
• Gender-diverse male spirit mediums in Northern Thailand: intersection of spiritual role, societal acceptance, stigma, and discrimination (2025). International Journal of Transgender Health. source
• Sinnott, M. (1999). Masculinity and tom identity in Thailand. Journal of Gay & Lesbian Social Services, 9(2–3). source
• Sinnott, M. J. (2004). Toms and Dees: Transgender Identity and Female Same-Sex Relationships in Thailand. University of Hawaiʻi Press. source
• Chokrungvaranont, P., Selvaggi, G., Jindarak, S., et al. (2014). The development of sex reassignment surgery in Thailand: A social perspective. The Scientific World Journal, 182981. source
• Exogenous hormone use among transfeminine individuals in Chiang Mai, Thailand (2024). source
• Aungkawattanapong, N., Prownpuntu, T., & Bongsebandhu-phubhakdi, C. (2024). Exploring transfeminine youth health disparities in Thailand. Health Equity. source
• BK Magazine. Thai queer cinema then and now. source
• Outright International. Thailand country overview. source
• International Bar Association (2025). Thailand's Marriage Equality Act: what comes next? source
• Jackson, P. A. (1997). Kathoey >< gay >< man: The historical emergence of gay male identity in Thailand. In L. Manderson & M. Jolly (Eds.), Sites of Desire, Economies of Pleasure: Sexualities in Asia and the Pacific (pp. 166–190). University of Chicago Press.
• Winter, S. (2006). Thai transgenders in focus: demographics, transitions and identities. International Journal of Transgenderism, 9(1), 15–27. source
• International Commission of Jurists (2011). Courtroom victory for trans people in Thailand! (analysis brief on Samart Meecharoen v. Defence Minister). source
• UNDP Thailand (2019). The lives of transgender people in Thai prisons. source