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Review

Healthcare Access for Transgender Women in Malaysia: A Narrative Review of Barriers and Enabling Factors

by
Lahari A. Telang
1,2,3,*,
Aoife G. Cotter
1,4,5 and
Abdul Rashid
2
1
Department of Infectious Diseases and Internal Medicine, School of Medicine, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
2
Department of Public Health, The Royal College of Surgeons in Ireland and University College Dublin (RCSI-UCD) Medical Campus (RUMC), George Town 10450, Penang, Malaysia
3
Department of Oral Medicine and Radiology, Penang International Dental College, Butterworth 12000, Penang, Malaysia
4
UCD Centre for Experimental Pathogen Host Research (CEPHR), Belfield, D04 V1W8 Dublin, Ireland
5
Infectious Diseases Department, Mater Misericordiae University Hospital, Eccles Street, D07 R2WY Dublin, Ireland
*
Author to whom correspondence should be addressed.
Sexes 2025, 6(3), 50; https://doi.org/10.3390/sexes6030050
Submission received: 2 June 2025 / Revised: 23 August 2025 / Accepted: 3 September 2025 / Published: 5 September 2025
(This article belongs to the Section Sexual and Reproductive Health, Sexual Medicine, and Psychosocial Remediation)
Browse Figure
Review Reports Versions Notes

Abstract

Malaysia is an upper-middle-income country and one of the few in Asia that has achieved Universal Health Coverage (UHC). Despite this, healthcare in Malaysia is less accessible to marginalized groups, such as transgender women, because a legal framework denies them gender-appropriate identification. Healthcare settings often fall short in addressing transgender-specific health needs. Transgender women face compounded stigma and discrimination, along with unique social and interpersonal challenges that greatly increase their risk of poor overall health. This narrative review explores the barriers to accessing and using primary, sexual, oral, and mental healthcare for transgender women in Malaysia. The discussion covers enabling factors like training healthcare workers, prioritizing transgender health needs, working with community-led organizations, implementing health policy reforms, and utilizing technology-based health interventions.

1. Introduction

Access to healthcare has been defined as the opportunity individuals have to utilize existing healthcare services in the context of healthcare needs [1]. Healthcare utilization, on the other hand, may be considered an alternative measure of access, even though it may not be clearly equated [2]. Conceptually, healthcare access and utilization are distinct yet interrelated since access is necessary for utilization [1]. Access to primary care is a significant determinant of health equality [2].

1.1. Health Care in Malaysia

Malaysia is an upper-middle-income country that has achieved Universal Health Coverage (UHC) with a well-developed public healthcare system that provides comprehensive healthcare services [2]. This means that the general public can access all health care services, general, sexual, mental, and oral care services, without exposing themselves to financial hardships [2,3]. A two-tiered healthcare system exists with both public and private sectors. Government-led public healthcare is heavily subsidized and accessible to all citizens, but long waiting periods are common. Urban areas have a greater density of primary healthcare clinics and health workers per capita than rural areas [4]. In contrast, the rapidly expanding urban private healthcare sector offers personalized care. Still, it is only accessible to those with the financial means, as primary and secondary care is provided fee-for-service [5,6]. Rural populations in Malaysia generally have lower socioeconomic status [7] and are less likely to seek healthcare from a healthcare practitioner [4]. Existing literature on access to healthcare in low- and middle-income countries (LMICs) is found to be sparse and more so regarding access to healthcare for marginalized groups [3].

1.2. Health of Transgender Women in Malaysia

Transgender women are a marginalized group of individuals in Malaysia, who in particular, experience unique social and interpersonal challenges that contribute immensely to their risk of acquiring illnesses [8,9]. The stress of disclosing their gender identity and feeling unsafe due to a lack of societal acceptance are believed to contribute to the avoidance of healthcare settings [10,11,12]. Transgender stigma persistently impacts the health and well-being of transgender individuals by functioning through a complex interplay between individual, community, and societal factors as described by the socio-ecological model [13]. Given the religious and legal contexts of Malaysian society, transgender women do not conform to the recognized binary gender categories and hence face compounded levels of stigma and discrimination [11], as well as criminalization [12,14]. Societal deep prejudices towards lesbian, gay, bisexual, and transgender (LGBT) individuals may jeopardize the already sensitive situation for transgender women in conservative societies like Malaysia [15], associating them with illicit drug use and illegal activities like sex work [16,17,18]. As a result, a highly sensitive situation is created, along with challenging living conditions that push transgender women to the fringes of society [12,19]. Often having to face family rejection and insecurity, they become vulnerable to substance misuse, poverty, and crime [10,19,20]. Health and well-being frequently take a back seat in the face of sensitive and challenging living conditions, with the basic determinant of health being undermined by legal processes and stigma [21,22].
Studies on barriers to healthcare access for transgender individuals in higher-income countries indicate issues such as lack of provider knowledge, denial of services, insufficient transgender-specific care in rural areas, and interpersonal barriers stemming from negative experiences, income and insurance challenges, stigma, and a lack of social safety and belonging [23,24,25,26,27,28,29]. However, the factors influencing healthcare access and utilization may differ for transgender individuals living in LMICs compared to those in higher-income countries. There is limited data regarding healthcare access, utilization, and health-seeking behavior among the local transgender community [11].

2. Methodology

This narrative review examines the state of healthcare for an under-researched population, transgender women in Malaysia, and synthesizes information on barriers and facilitators to healthcare access and utilization. Given the limited number of peer-reviewed studies specifically focused on transgender women and healthcare utilization in Malaysia, a broad narrative approach was used. Initial searches were done in PubMed, Scopus, Web of Science, PsycINFO, and CINAHL. Additional sources were identified through Google Scholar and grey literature repositories, including organizational reports from SEED Foundation, PT Foundation, Malaysian AIDS Council, and UNAIDS. The search aimed to capture peer-reviewed articles and relevant non-indexed materials addressing health care access and utilization among transgender women in Malaysia. ((“Transgender Persons” [MeSH] OR “transgender women” OR “transwomen”) AND (“Health Services Accessibility” [MeSH] OR “healthcare access” OR “Health Services” [MeSH] OR “Health Care Utilization” OR “Health Services Utilization”) AND (“Patient Acceptance of Health Care” [MeSH] OR “facilitators” OR “enablers” OR “healthcare-seeking behavior” OR “barriers and facilitators”) AND (“Malaysia” [MeSH] OR Malaysia)) NOT “Men who have sex with men” [MeSH].

Reflexivity and Positionality

The authors of this review identify as cisgender heterosexuals with experience working with transgender women. Two of the three authors are from Malaysia, one of whom is a Malaysian national, and the other has extensive working experience in healthcare in Malaysia. All authors involved ensured a reflexive approach while writing this review, ensuring it was free from potential cultural and personal biases.

3. Barriers to Healthcare Access and Utilization by Transgender Women in Malaysia

3.1. Primary Healthcare

The healthcare needs of transgender women might not be fully addressed, even though health facilities are accessible to everyone through Malaysia’s UHC system [21]. Moreover, inadequacies in addressing transgender-specific health issues are compounded by policies and laws that prohibit changing one’s gender for any reason [30]. Laws against ‘cross-dressing’ and ‘men posing as women’ particularly affect transgender women, making them hesitant to seek healthcare for the fear of criminalization or further discrimination [31,32]. An example of such weaknesses in healthcare settings is the situation where transgender women are placed in male wards when hospitalized [10]. Rejections of health insurance claims due to discrepancies in physical appearance and gender marker on identification cards have also been reported [31].
The lack of provisions for gender-affirming procedures such as feminizing hormone prescriptions, surgical options, and aftercare as part of routine services in public healthcare settings contributes to these inadequacies in healthcare [11,21,30,31]. A study conducted on transgender women in 2018 in Kuantan revealed that 94.2% of the participants purchased their hormones over the counter from local pharmacies [33]. A similar report in 2021 on the West Coast of Peninsular Malaysia found that a significant proportion of transgender women (71%) resort to self-medication during their transition process, predominantly involving the use of unregulated and unsupervised hormone treatments, including illegal gender-affirming procedures, which, in many cases, lead to overall poor health consequences [34].
Another vital aspect is stigma and discrimination in healthcare settings, which create significant barriers to healthcare access and utilization by transgender women [11,30]. Negative attitudes of healthcare students toward marginalized populations, especially those living with HIV, have been reported [35] along with prejudices against sexual and gender minorities [15]. In this cultural context of the negative perception of transgender women in the Malaysian community, verbal and physical maltreatment, or even refusal of access to healthcare, have also been reported [36]. Additionally, transgender stigma, fear, and personal shame have been identified as factors that play an essential role in physicians’ role in discrimination in healthcare settings [37]. The lack of healthcare professionals who are experienced in managing the unique health concerns of transgender women and the dearth of culturally sensitive health promotion programs contribute to the issue of poor healthcare access and utilization [8,37]. This further deepens the barriers to healthcare access and utilization by transgender women due to fear of stigmatization and overall perception of low quality of healthcare [8,36].

3.2. Sexual Healthcare

Transgender women, along with men who have sex with men (MSM) and people who use drugs, are one of the key populations particularly vulnerable to Human Immunodeficiency Virus (HIV) infection [10,38]. According to the Ministry of Health, Malaysia, the estimated number of transgender women who are living with HIV in 2017 was reported to be 10.9% [39]. However, in a 2018 study on transgender women sex workers in Greater Kuala Lumpur, researchers reported a much higher prevalence of HIV at 12.4%, along with high rates of syphilis [40]. Moreover, a recent study on the HIV continuum of care reported that only 12.5% of HIV-infected transgender women sex workers were currently taking Anti-retroviral Therapy (ART) [41]. Urban transgender women in Malaysia, however, felt targeted as a key population being subsumed in health campaigns along with MSM [8], which is perceived to impact their access to HIV care negatively [11,18,42]. Gaps in accessibility to sexual health services are pronounced among marginalized groups, especially transgender women from low-income households [43]. Factors that influence the decision to utilize sexual healthcare services, including HIV/Sexually transmitted Infections (STI) clinics, may be influenced by fear of discrimination, influenced by the socio-political environment [21,41,44] further contributing to delays in access to ART for those who need it the most [45].

3.3. Oral Healthcare

Similarly to general healthcare services, Malaysia’s oral healthcare sector is also dichotomous [2]. According to a nationwide report, the National Health and Morbidity Survey, Malaysia 2019, oral healthcare utilization among the general adult population is generally low, with factors such as demographics, socio-economic background, beliefs, and attitudes contributing to the low utilization [46]. However, limited information is available about oral healthcare access and utilization among the transgender community [8,47], which makes it difficult to assume that the barriers or facilitators they encounter are the same as those in general healthcare settings in Malaysia. A 2020 study reported overall poor oral health-related quality of life (OHRQoL) among transgender women in a northern state of Malaysia, with varying degrees of dental anxiety compounded by experiences of discrimination in dental care facilities [47]. A more recent study examining the oral healthcare needs and dental service use among transgender women in Northern Malaysia found that participants perceived little need for dental care and avoided dental visits [8]. Additionally, a gap in the availability of dental services tailored to the community’s needs was identified, which leads to the perception and use of unprofessional aesthetic dental care as a more accessible option [8]. Both studies highlight the importance of improving overall oral healthcare for transgender women while considering the cultural beliefs about dental services within the community.

3.4. Mental Healthcare

Transgender individuals in Malaysia face significant mental health challenges due to various barriers in accessing appropriate services, including exposure to minority stressors, concerns about confidentiality, and conflicts arising from religious beliefs [19,22,48]. In Malaysia, where religion plays a central role in shaping social norms, transgender women often face stigma due to interpretations of religious teachings that reject gender diversity [10]. This not only impacts their mental well-being by fostering internalized shame and social exclusion [19], but also creates barriers to accessing mental healthcare, as some providers may allow religious beliefs to influence their attitudes and treatment practices [22,48]. Studies describing the barriers and facilitators to professional mental health-seeking behavior among the LGBT community in Malaysia attribute these to a lack of resources and a shortage of suitable professionals [22,48]. These shortages, along with the dearth of information about LGBT-friendly services and the prohibitive costs, are significant obstacles to accessibility [22,48]. Although in most mental health studies done in Malaysia, transgender women were subsumed into the ‘LGBT’ umbrella, they, in particular, pointed out their unmet mental healthcare needs due to a lack of preferred professionals, questionable competency of the therapist, and skepticism about the effectiveness of the service [8,19,22]. Judgmental attitudes and breaches of doctor-patient confidentiality in government settings were also cited as reasons for opting for more expensive private service providers [8,17,47]. Conversely, community support, along with inclusive, non-discriminatory, and supportive counsellors, was reported as a facilitator for seeking professional mental health services [22]. Medical gender affirmation also positively influences mental health outcomes among transgender individuals [49].

4. Enabling Factors of Healthcare Access and Utilization by Transgender Women Malaysia

Building on valuable insights from worldwide studies, a deeper understanding of the key factors that enable and improve healthcare access and use among the transgender community can lead to meaningful service enhancements. Several documented facilitators can be tailored to fit the local context to develop a more inclusive and supportive healthcare system.

4.1. Inclusivity Training for Healthcare Workers

Integrating cultural safety [50], culturally competent and gender-affirming training in medical and dental curricula can foster more inclusive attitudes toward gender-diverse populations [15,35]. Education is a key pillar of cultural competence [51]. Improving healthcare providers’ knowledge and attitudes, combined with policy reform and community collaboration, can help reduce systemic inequalities, paving the way for more personalized and respectful care [51]. Exposure to transgender individuals in healthcare settings, coupled with an understanding of their unique health needs and recognition that they deserve equitable care, significantly reduces stigma and discriminatory behaviors among healthcare professionals [37]. Coping interventions targeting multiple levels of stigma can create opportunities to reduce stigma-related adverse health effects, potentially [13,26]. Studies have shown that structured intergroup contact interventions can be effective in reducing stigma, and informal, equal-status interactions can serve as cost-effective methods for reducing transphobia [52]. A practical guide to trans-specific healthcare in Malaysia was drafted as a bilingual document in 2020, offering advice on the assessment and management of transgender patients in healthcare centers [53]. Making accessible documents available at healthcare and educational facilities can foster discussion, reduce discrimination, and address systemic inequalities in transgender health through improved provider education, policy reform, and community collaboration.

4.2. Prioritizing Trans-Specific Health Needs

A more substantial commitment to integrating the health needs of marginalized communities, including transgender individuals, into national health priorities is needed. This can be achieved by embarking on transgender health research to understand their healthcare needs, with improved funding opportunities [21].
International guidelines recommend gender-affirming treatment, which includes hormone therapy, surgery, voice and communication therapy, and various aspects of primary and sexual healthcare for transgender women [54]. Following these guidelines, collaborations can be encouraged between healthcare professionals, policymakers, and community members who can advocate for affirming transgender healthcare [54]. Flexible adoption of these guidelines will facilitate the integration of trans-specific health needs into national priorities.
Addressing the gaps in empirical data required for the scale-up of HIV prevention programs can enhance the ongoing efforts by the Ministry of Health towards the goal of reducing HIV sexual transmission [44]. The Malaysian National Strategic Plan for Ending AIDS (NSPEA) 2016–2030 has laid out key strategies for reaching zero new infections, zero discrimination, and zero AIDS-related deaths [55]. The NSPEA includes trans-specific targets for most categories of the HIV continuum of care, with specific community-led HIV/STI services for mitigating sexual transmission among transgender individuals [55]. In 2015, the Ministry of Health launched the ‘STI-friendly clinics’ as part of the Differentiated HIV Services Delivery for Key Populations (DHSKP) to decentralize HIV care and treatment [56]. The aim was to create a one-stop-shop experience through the integration of health services while involving community health workers and peer support networks in a friendly, stigma-free environment [56]. Through the public health system, the government aims to provide affordable and universal access to care for all [55], including no-cost ART to all people with HIV [41]. However, despite these efforts, key populations remain hidden, hard to reach, and often found not utilizing public health services, especially HIV screening and testing services [44]. Expanding the national UHC system to include sexual health services with emphasis on adequate coverage, equity, and financial protection has also been advocated as a significant step towards equitable healthcare [43]. Drawing from similar contexts involving transgender women in a South African study, equitable and inclusive health management can be achieved through novel strategies such as collaborating with traditional healers to enhance access to healthcare [57].

4.3. Engagement Through Community-Led Organizations

A step up in support for community-led organizations that constantly engage, educate, and empower the local transgender community may help in improving access to healthcare, including HIV/STI services [58,59]. One significant step was the launch of STI-friendly clinics through collaboration with the Malaysian AIDS Council, aiming to enhance testing, diagnosis, and treatment adherence to positively influence the HIV care continuum [56]. However, follow-up literature regarding the nature of training provided to clinicians and the overall success of this approach is sparse [58].
Creating supportive communities for transgender women is essential for enhancing their physical and mental health. Promising examples of transgender-led community-based organizations in the neighboring states include the Tangerine clinic in Thailand [59] and Love Yourself [60] in the Philippines. These are sustainable models of clinics that provide access to comprehensive and quality health care services through the involvement of members of the transgender community who play a pivotal role in running the clinic [59,61,62]. The model trains transgender lay providers to engage and retain patients in primary care by providing counselling services and encouraging the uptake of transgender specific services like gender affirming care in the clinic [61,63]. Strengthening existing local community-led organizations can provide healthcare and social support systems that effectively address the needs of transgender individuals, while fostering safe environments that protect them from gender-based discrimination and stigma prevalent in society.
To scale up Pre-exposure prophylaxis (PrEP) for transgender women in Malaysia, it is essential to engage trans communities, utilize trans-inclusive research and marketing, and train providers in gender-affirming care, which includes hormone provision [64]. Healthcare guidelines must address the unique barriers that transgender women encounter in PrEP uptake and adherence [64]. PrEP in Malaysia is registered as an ART drug but is currently not licensed for HIV prevention. Initially, PrEP was only available in private clinics for a fee; however, thanks to recent efforts by the Ministry of Health, PrEP has been dispensed for free at selected public health clinics since 2023 [65]. Through ongoing efforts, key populations have the opportunity to benefit from PrEP uptake and scale-up initiatives.

4.4. Healthcare Policy Reforms

Stigma and exclusion faced by transgender women are linked to poor health outcomes worldwide, highlighting the importance of transgender rights for health [66]. Structural changes in the healthcare system in Malaysia, including the introduction of microfinancing schemes for rural transgender individuals, could expand access to private healthcare [67]. By engaging with local community-led groups, infrastructure improvements can be envisioned through renewed healthcare policies to establish a more inclusive healthcare system [68]. Existing cross-sectoral guidelines and policies need to be reviewed to enhance access to healthcare for all marginalized groups. The Malaysian Health White Paper 2023 outlines plans to improve both access to and the quality of healthcare for vulnerable and high-risk groups [69]. However, gender-diverse individuals have not been explicitly mentioned in this paper [69].
Building on insights from the ‘quiet transgender revolution,’ including transgender individuals can progress within rigid systems when such change aligns with the organization’s own interests [70]. A relevant application to the Malaysian healthcare context involves overcoming structural inertia and developing supportive policies through strategic, context-aware engagement with institutions [70]. Reforming public health care can help support transgender women by aligning public health goals with institutional prestige and sociocultural acceptance. While framing Malaysia’s healthcare challenges within a broader global framework, it is noteworthy to reflect on the socio-political and religious conditions within the country [71]. Targeted policy reforms tailored to local constraints, focusing on institutional exclusion and provider discrimination, are essential for improving access to essential healthcare.

4.5. Technology-Based Health Interventions

Health interventions targeting key populations have been shown to increase awareness and decrease stigma, thereby improving access to healthcare [72]. With smartphone availability and internet penetration being among the best in South East Asia [73], using mhealth interventions could prove to be particularly effective in Malaysia. Examples of such interventions are MyLink2care, aiming to improve HIV testing and PrEP uptake and adherence in transgender women [74]; and MsRadiance, aiming to enhance oral health awareness and dental service utilization along with improving awareness of oral transmission of sexually transmitted infections [75].

5. Conclusions

This narrative review recognizes that transgender women’s healthcare needs are comprehensive and provides insights into various healthcare areas impacting transgender women in Malaysia. Although narrative reviews might not capture every study and can be subject to selection bias, the authors believe this review focuses on the overall health of transgender women and identifies underrecognized issues, such as oral health care utilization. Given the socio-legal context in Malaysia surrounding transgender rights, this narrative review provides essential information for advocating transgender healthcare. A summary of the findings from the review has been displayed while situating the Malaysian context within the broader global landscape of transgender health by utilizing the socio-ecological model [76,77,78]. Figure 1 shows the socio-ecological model highlighting multiple levels of interacting barriers and enablers of transgender women’s healthcare in Malaysia.
Repeated systematic exposure to social stressors, such as societal exclusion and legal issues, is suggested to cause inequality in health care, contributing to disease and disability among sexual and gender minorities, including transgender individuals [78]. Capacity building through community-led organizations, combined with awareness-raising initiatives targeting the transgender community, could contribute to an overall improvement in healthcare access. Integrating healthcare systems with community services by providing a framework for policymakers, researchers, and advocates to work towards a more inclusive and equitable healthcare system may be the way forward to improving access for transgender women in Malaysia. A crucial factor, though, is the alignment of public health efforts with national policies and the availability of the right implementation tools.

Author Contributions

Conceptualization, L.A.T., A.G.C. and A.R.; methodology, L.A.T.; writing—original draft preparation, L.A.T.; review and editing, A.G.C. and A.R.; visualization, A.G.C.; supervision, A.R. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

No new data were created or analyzed in this study. Data sharing is not applicable to this article.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript
UHCUniversal Health Coverage
LMICsLow- and Middle-Income Countries
LGBTLesbian, Gay, Bisexual, and Transgender
MSMMen who have Sex with Men
HIVHuman Immunodeficiency Virus
STISexually Transmitted Infections
ARTAnti-retroviral Therapy
OHRQoLOral Health-Related Quality of Life
NSPEANational Strategic Plan for Ending AIDS
AIDSAcquired Immunodeficiency Syndrome
PrEPPre-exposure Prophylaxis

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Figure 1. The socio-ecological model highlighting barriers and enablers of health care access and utilization by Transgender women in Malaysia.
Figure 1. The socio-ecological model highlighting barriers and enablers of health care access and utilization by Transgender women in Malaysia.
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MDPI and ACS Style

Telang, L.A.; Cotter, A.G.; Rashid, A. Healthcare Access for Transgender Women in Malaysia: A Narrative Review of Barriers and Enabling Factors. Sexes 2025, 6, 50. https://doi.org/10.3390/sexes6030050

AMA Style

Telang LA, Cotter AG, Rashid A. Healthcare Access for Transgender Women in Malaysia: A Narrative Review of Barriers and Enabling Factors. Sexes. 2025; 6(3):50. https://doi.org/10.3390/sexes6030050

Chicago/Turabian Style

Telang, Lahari A., Aoife G. Cotter, and Abdul Rashid. 2025. "Healthcare Access for Transgender Women in Malaysia: A Narrative Review of Barriers and Enabling Factors" Sexes 6, no. 3: 50. https://doi.org/10.3390/sexes6030050

APA Style

Telang, L. A., Cotter, A. G., & Rashid, A. (2025). Healthcare Access for Transgender Women in Malaysia: A Narrative Review of Barriers and Enabling Factors. Sexes, 6(3), 50. https://doi.org/10.3390/sexes6030050

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