The search captured 1844 peer-reviewed articles and 497 grey literature sources in total. Figure 1 shows the process of identifying relevant peer-reviewed journal articles and grey literature sources. We removed duplicates across the different search engines before reviewing the peer-reviewed article abstracts and the grey literature full texts. After the full text review, we identified a total of 76 [16, 19–93] peer-reviewed articles and 39 [7, 8, 17, 94–129] grey literature sources which were included in the scoping review.
Description of peer-reviewed studies
Among the 76 peer-reviewed articles included, 37% (28) were quantitative studies [20, 23, 25–27, 29, 30, 34, 37–40, 42, 43, 46, 50, 56, 59–61, 65, 73, 78, 79, 86, 91–93], 36% (27) were qualitative studies [19, 22, 24, 31, 32, 36, 41, 44, 45, 54, 57, 58, 63, 66, 67, 69–71, 74–76, 83–85, 87–89], 22% (17) commentaries or descriptive analyses [16, 21, 28, 35, 47–49, 51–53, 62, 68, 72, 77, 80, 81, 90], and 5% (4) mixed methods studies [33, 55, 64, 82].
Geographically, 81% (48/59) of the quantitative, qualitative, and mixed methods studies were concentrated in urban areas, with Bangkok or Chiang Mai being a primary or sole recruitment site in 88% (42/48) of all urban studies. Only 1 (2%) study took place in rural Thailand, while 5 (8%) were conducted online, and 5 (8%) were regional studies conducted at multiple sites in Thailand.
As Fig. 2 shows, the topic of LGBT+ inclusion in Thailand has been increasing in peer-reviewed articles over the past two decades. The majority (79%; 60/76) of articles were published after 2010.
Figure 3 shows the focal populations among the peer-reviewed articles. Across 7 population categories identified, 26% (n = 20) of the articles addressed more than one population, including a stated focus on LGBT+ people as a group. Of the 76 articles, 42% (n = 32) focussed on gay men or men who have sex with men (MSM); among these, the majority (n = 18 articles) used or included the term “gay” or “gay men” (one used “homosexual”), while the remainder only used the behavioral terminology, MSM. As the latter may include men who self-identify as heterosexual, bisexual, or gay, we heretofore refer to the broader category as gay men and other MSM. Thirty-two articles focused on transgender women (12 of these addressed both gay men and transgender populations). Seventeen articles addressed LGBT+ populations broadly, while 4 focussed on bisexual men and women, 4 on lesbian women, and 2 on transmasculine individuals. Eight articles targeted the “general population” or cisgender (i.e., whose gender identity ‘matches’ their sex assigned at birth) heterosexual individuals, largely as a comparator to LGBT+ groups or to gauge their attitudes toward LGBT+ people.
Figure 4 shows the number of peer-reviewed articles that addressed each domain of our inclusion typology. Over half (57%; n = 43) of the 76 articles addressed multiple domains of inclusion. Accordingly, we identified all domains that were substantively addressed in each article, with a total count of 161. Forty-eight of the articles addressed health, the most prevalent among the six domains of inclusion; 35 articles addressed the family domain and 25 addressed political and civic participation.
Description of the Grey literature
Of the 39 grey literature sources, 59% (23) were commentaries or descriptive analyses of LGBT+ issues (including NGO reports or legal analyses), 23% (9) utilized qualitative research methods, 3% (1) used quantitative methods, and 15% (6) were large-scale (n = 1500+) mixed methods studies primarily conducted by quasi-governmental organizations (e.g., World Bank or UNDP). The focal population of interest of a majority (n = 25) of the grey literature sources was LGBT+ people as a group, rather than specific subgroups. Of the remaining grey literature sources, 7 focussed on gay men and other MSM, 5 on transgender persons (2 on transgender women, 1 on transmasculine individuals), 4 targeted the general population, and 1 concentrated on lesbian women, bisexual women, transgender persons and intersex individuals.
The vast majority (97%; 38/39) of the grey literature included was published after 2010; the only exception was a 2007 report by Thailand’s National Human Rights Commission. Geographically, among the 16 empirical studies, 5 were regional and conducted at multiple sites, 4 were conducted in Bangkok, 2 in an unspecified city, 3 online, and 2 were multi-country pan-Asian studies. Over three-quarters of the grey literature sources (77%; n = 30) addressed multiple domains of inclusion. Across the total count of 137 domains addressed, 21% (n = 29) examined health, similarly the primary domain of focus in the peer-reviewed literature; 20% (n = 27) addressed political and civic participation, 17% (n = 23) personal security and violence, 15% (n = 21) education, 15% (n = 21) economic well-being, and 12% (n = 16) family.
Political and civic participation
Overall, the peer-reviewed and grey literature addressing political and civic participation coalesced in the observation that while Thailand “does not conduct active legal repression of sexual/gender minorities”, the law tends to ignore their existence (, p.11). This failure to legally acknowledge the existence of LGBT+ individuals creates numerous participatory barriers, two of the most significant examples being the inability to change one’s legal gender and the absence of generalized antidiscrimination legislation for LGBT+ individuals.
Half (27/54) of the publications that addressed political and civic participation, underscored the fact that transgender individuals currently have no recourse to change their legal gender [7, 8, 17, 22, 31, 33, 36, 52, 69–72, 77, 90, 96, 97, 99, 102–104, 113–115, 118, 122–124, 126]. As a result, the gender listed on state-issued identity cards is often incorrect for transgender individuals. This incongruence has been reported to cause numerous issues with respect to employment, foreign travel, and medical services, often acting as a trigger for discriminatory treatment. For example, Suriyasarn  reported that as a result of the mismatch between official documentation and physical appearance, hospitals can take significant extra time to verify a transgender individual’s identity, at times causing treatment delays. Similar problems have been reported in accessing government services  and social services .
The second most-identified challenge (19/52 articles) pertained to the absence of generalized antidiscrimination legislation for LGBT+ individuals [7, 8, 17, 22, 31, 36, 39, 54, 68, 69, 71, 77, 97, 103, 104, 121, 124, 125]. Although the Thai constitution prohibits discrimination on several grounds, including sex, LGBT+ individuals are largely unprotected. The recently enacted Gender Equality Act B.E. 2558  has gone some distance toward remedying this situation for transgender individuals [122, 125]; however, substantial gaps remain as it is “unclear whether this protection extends to sexual orientation” (, p.19, 121).
The 37 publications addressing education as it relates to LGBT+ populations nearly universally underscored the persistent discrimination that LGBT+ individuals face in the Thai education system. A World Bank  study (n = 2302) indicated that 23% of transgender people, 11% of lesbian women, and 6% of gay men reported that they had experienced discrimination in accessing some form of education or training services. A UNDP  study identified even higher prevalence among their sample (n = 1349), with 41% of LGBT+ individuals overall reporting that they had experienced discrimination as a student. The proportion for transgender women was the highest, at 61%.
Educational discrimination takes different forms. Fourteen of the 37 sources highlighted bullying and social victimization as significant source of discrimination [7, 8, 33, 40, 71, 82, 87, 96, 103–106, 113, 125]. In a large-scale study , the majority (56%) of the LGBT+ individuals (n = 2070) experienced bullying in school because of their LGBT+ status. This included verbal/social abuse (e.g., name calling, online bullying, social exclusion), physical abuse (e.g., kicking and slapping), and sexual abuse (e.g., unwanted touching of the breasts, penis or buttocks). A World Bank  report conducted in Thailand indicates that this form of abuse is especially concerning because it increases the risk that many LGBT+ students will not finish their schooling, in part, because they may adopt avoidance strategies like skipping school or leaving school altogether. The UNDP  noted that over twice as many Thai LGBT+ students who had been bullied (33%) compared to those who had not been bullied (15%) reported unauthorized school absences.
Beyond acts of bullying, many LGBT+ students are subjected to stigmatizing portrayals of LGBT+ populations in school curricula (14/37 articles) [7, 54, 71, 72, 85, 99, 100, 104–106, 110, 113, 123, 125]. In fact, the 2008 Basic Education Core Curriculum in Thailand covers sexual and gender diversity under the rubric of ‘sexual deviancy’ . This negative portrayal also fuels curricular gaps, including topics related to safer sex among same-sex partners. A UNDP  report indicated that nearly two-thirds (64%) of LGBT+ individuals stated that the sex education they had received excluded topics related to sexual orientation and gender identity/expression. Several authors hypothesize that this gap may contribute to the very high rates of HIV infection among young MSM in Thailand .
In addition to these curricular gaps, LGBT students reported pressure from teachers to avoid pursuing certain subjects or high-status fields of employment, such as law or medicine, largely based on stereotypical presumptions about their character or ability [8, 129].
Transgender students face unique challenges related to school-wide dress codes (13/37 articles) [7, 70, 71, 87, 100, 103, 104, 113, 120, 125, 126, 128]. Generally, students are required to wear uniforms or have hairstyles that reflect the gender on their identity cards; this can lead to situations where they must either wear clothing that disaffirms their identity or be excluded from their education entirely [70, 71]. Several organizations report that attempts to deviate from the dress code can result in other sanctions, including refusals to allow students to write examinations or submit coursework [103, 129].
Forty-six (41%) of 115 sources addressed LGBT+ family-related topics, suggesting high relevance to LGBT+ inclusion. The prominence of family may be influenced by the Thai sociocultural context, in contrast to Western countries where family may be less of a fulcrum of life across the lifespan. A majority of these publications (24/46) addressed persistent social isolation, rejection, and discrimination experienced by many LGBT+ individuals in their family despite the powerful significance of family in their lives [7, 17, 25, 32, 33, 37, 38, 44, 56–58, 70, 74, 82, 92, 93, 96, 99, 106, 111, 113, 115, 116, 123]. Several sources specifically underscored the challenges associated with filial obligations and the strong familial pressure to conform that is placed on LGBT+ children in Thai culture [48, 63, 64, 69, 71]. A UNDP  national survey (n = 1349) indicated that nearly half (48%) of respondents stated that they had experienced at least one form of discrimination within their family. This included pressure to terminate same-sex relationships or enter heterosexual ones, verbal attacks, or being subjected to economic control. A World Bank  study (n = 868) noted that many LGBT+ individuals reported experiencing violence in their families because of their LGBT+ status. For some LGBT+ youth, familial rejection and discrimination resulted in ejection from the family home  and termination of familial support for their education . In a study by Kittiteerasack et al.  (n = 411), the authors noted high levels of family rejection and reported that approximately half of LGBT+ adults in their study were not out to their family; feeling constrained to hide one’s sexual orientation or gender identity was associated with elevated levels of depression.
Among seven articles that addressed family dynamics related to high rates of rejection, they note substantial pressure is placed on LGBT+ young people to be ‘good’ children and preserve family harmony [54, 69–72, 87, 88]. In some families, being gay is viewed as a defect and there may be intense pressure to adopt heteronormative mannerisms and find an ‘appropriate’ heterosexual partner; failure to conform risks loss of face for the family, and the subsequent rejection of the gay family member .
Some LGBT+ individuals appear to manage this pressure with actions rarely described in Western contexts. Five articles indicated that for many LGBT+ individuals, sending money home to their parents, in accordance with filial obligations, can improve familial relationships, in effect “buying” them additional space to express their identity [48, 63, 64, 69, 71]. However, this strategy can have downsides. For example, the limited work and educational opportunities afforded to some transgender individuals means that they are often constrained to engaging in sex work to support their family [63, 64, 71], with its various associated health risks, including HIV infection [63, 64].
Finally, a number of legal hurdles in Thailand prevent LGBT+ individuals from forming their own families. Thirteen publications addressed the difficulties posed by the absence of legal recognition of same-sex marriage [7, 8, 17, 22, 31, 69, 96, 97, 99, 103, 108, 123, 125] and related difficulties in accessing employer pensions and benefits, tax benefits, hospital visitation, and medical decision-making [17, 108]. Gender-specific terms in Sections 1448–1460 of Part II (Conditions of Marriage) in Chapter V (Family) of the Civil and Commercial Code permit marriage only between members of the opposite sex. Many transgender individuals are also barred from marrying, often related to inability to change one’s legal gender .
Personal security and violence
Thirty-five publications addressed threats to the personal security of LGBT+ individuals. This included forced sex and physical violence, and a reluctance to report these instances in the context of police harassment, all of which had negative consequences for LGBT+ people’s health. Twelve studies reported higher rates of forced or coerced sex than among the general population [7, 17, 33, 39, 43, 59, 70, 78, 82, 86, 96, 113], with six-fold higher rates of forced sex reported among young gay and bisexual men and 1.5-fold higher rates among young lesbian and bisexual women (n = 1725) compared to their cisgender heterosexual counterparts . A UNDP  study (n = 1349) reported that 16% of LGBT+ people had been sexually assaulted, with 21% , 20% , and 18%  reported in other studies of gay men and transgender individuals. Ten sources highlighted persistently high rates of physical violence experienced by LGBT+ individuals because of their sexual orientation or gender identity [7, 17, 33, 96, 103, 105, 111, 113, 115, 123]. A World Bank  survey of Thailand (n = 3502) indicated that 27% of LGBT+ individuals had experienced family violence due to their LGBT+ status, with especially high prevalence (89%) among transgender individuals.
Despite elevated rates of forced sex and violence, LGBT+ people in Thailand are often reluctant to seek assistance from authorities. Thirteen publications identified police harassment and violence as a deterrent to seeking help from authorities [7, 33, 67, 70, 96, 99, 108, 113, 114, 118–120, 126]. Overall, 8% of LGBT+ individuals report harassment by police . Transgender women, especially those engaged in sex work, have been the subject of numerous instances of documented police brutality  and are often the target of selective implementation of nuisance and/or vagrancy laws by police [96, 113]. In many cases, police may not take reports of sexual violence against LGBT+ individuals seriously, negating its treatment as criminal conduct [118–120]. Furthermore, Fongkaew et al.  and Sinnott  described a toxic media environment and suggest that this contributes to a climate in which LGBT+ violence victimization is accepted.
Several articles addressed repercussions of violence in negative health outcomes, including HIV infection , illicit drug use , depression and suicide [59, 82, 86, 125].
Thirty-five publications addressed the economic well-being of LGBT+ people in Thailand, 26 of which highlighted the pervasive discrimination faced by many LGBT+ people in the job market [7, 8, 17, 31, 33, 34, 44, 57, 63, 64, 69–72, 87, 90, 93, 99, 103, 108, 109, 113, 115, 120, 121, 129]. Workplace discrimination takes many different forms, including overly restrictive dress codes that inhibit gender expression [54, 70, 71], mandatory HIV testing as a condition of employment [8, 33, 71], workplace harassment [17, 71, 121], refusing to hire or promote LGBT+ workers because of their gender identity/sexual orientation [17, 121, 129], or simply firing them if their status becomes known . Educational discrimination also exerts a potent impact on job market disparities as it often effectively denies many LGBT+ individuals the necessary qualifications for certain types of work (e.g., law, medicine, etc.) [17, 121]. The Gender Equality Act makes it illegal to discriminate “due to the fact that the person is male or female or a different appearance from his/her own sex by birth” (Article 3) (, p.9). The fact that Thai law does not appear to explicitly prohibit discrimination on the basis of sexual orientation in the workplace or in the education system [17, 103, 129] may mean that a substantial proportion of LGBT+ individuals are left without recourse in these situations.Footnote 1
A large-scale World Bank  study (n = 2302) indicated that job discrimination was generally more severe for transgender individuals, 60% of whom reported discrimination in the workplace, compared to 29% of lesbian women and 19% of gay men. Several articles suggest that this disparity is due to the fact that visibly non-normative gender presentation often acts as a trigger for discrimination, with transgender individuals often having more difficulty hiding their LGBT+ status [8, 71, 72]. Indeed, in the World Bank  study, the prevalence of hiding one’s identity among different LGBT+ subgroups—41% of gay men, 25% of lesbian women, 23% of transgender individuals—was inversely associated with the prevalence of experiencing workplace discrimination. Nevertheless, the persistent stress of concealing one’s sexual orientation or gender identity and the vigilance it demands, along with anticipated rejection (i.e., minority stress), have negative repercussions for one’s mental health and wellbeing . The fact that Thai law does not currently allow transgender individuals to change their identity documents to reflect their gender further contributes to their being outed as gender non-conforming to potential employers [8, 69, 90, 103, 120, 129].
Overall, the literature on economic well-being suggests that these discriminatory barriers can severely limit employment opportunities for LGBT+ individuals, constraining their opportunities to stereotypical (e.g., hairdressing) or risky professions (e.g., sex work) . Law enforcement, military, religious, and civil service institutions were identified as least accessible, while industries related to beauty and wellness, hospitality, retail, and sex work were among the most accessible [8, 17].
Health was the most frequently addressed domain, comprising 74 of 115 studies. This was in large measure driven by extensive research literature on HIV: 46 sources addressed HIV risk and related challenges for LGBT+ populations. Moreover, these numbers understate the magnitude of HIV research on LGBT+ populations in Thailand as many HIV-related articles were excluded because they did not address concepts related to inclusion, such as health disparities or discrimination in healthcare.
Many HIV-related publications (13 sources) describe specific risk factors for certain LGBT+ groups, such as kathoey sex workers—who experience increased risk as a result of illicit drug use, engaging in condomless anal sex, or having been abused by a father or brother —and MSM, as a result of sex work, drug use, past sexual violence, or experiences of discrimination [34, 78]. These HIV risk factors are exacerbated by systemic discriminatory practices and policies. Several sources implicated stigma in the healthcare system, which creates barriers to HIV testing and prevention [59, 131], as well as a hostile legal environment and police conduct (e.g., raids, harassment etc., during the Social Order Campaign) that can discourage or disrupt safer sex programs [94, 126]. Other scholars highlight the failure of the Thai school system to teach meaningful sex education to LGBT+ students as another driver of high HIV rates among some LGBT+ populations [100, 131].
The relationship between discrimination and poor health outcomes was broadly evident across many sources, including physical health [7, 17, 23, 28, 33, 34, 71, 72, 94, 98, 100, 101, 103, 104, 106, 115, 123, 126, 127] and mental health outcomes. With respect to mental health issues (11 studies), LGBT+ populations are vulnerable to elevated rates of social isolation, depression, and suicidal ideation [34, 40, 56, 82, 86, 92, 93, 116]; negative outcomes are often triggered by discrimination, bullying and/or violence in family, education, economic and/or healthcare domains [7, 8, 105]. A number of sources indicated that one of the primary mediators for this relationship was the poor care and/or discriminatory treatment that many LGBT+ persons receive in the healthcare system. Twenty-six sources called attention to multiple forms of discrimination, spanning indirect to direct, from healthcare providers: inappropriate disclosure of private information or lack of awareness and competence in addressing LGBT+ health issues; applying unequal standards of care to LGBT+ vs. cisgender heterosexuals; characterizing LGBT+ status as a mental illness; to outright refusals to treat LGBT+ people [7, 8, 17–20, 34, 57, 59, 65–67, 69–71, 74, 77–79, 84, 99, 103, 104, 108, 113, 117, 124]. In part, this discrimination may reflect the legacy of the codification of “homosexuality” as a mental illness, delisted by the Thai Ministry of Public Health in 2002—a decision characterized by a former director of the Department of Mental Health as one that “lags behind academic consensus by more than 30 years” [77, 81]. In a study of gay men/MSM and male sex workers (n = 260), over one-third (43%) reported that healthcare providers exhibited hostility towards them and 31% reported being given less attention than other patients . A UNDP  study indicates that nearly 20% of transgender women reported being refused in-patient accommodation on the women’s hospital ward. Finally, a study of gay men and other MSM, including male sex workers, and transgender women (n = 408) found that those who reported higher levels of HIV stigma were 28% less likely to have ever been tested for HIV , identifying a direct link between stigma and HIV risk.
Identity cards pose widespread problems in the healthcare context, creating a situation in which transgender people are forced to undergo a demeaning process to prove who they are [17, 103]. The cumulative effect of these barriers is that many LGBT+ individuals avoid the healthcare system because of the widespread, and often accurate, perception that they will be subjected to poor or discriminatory treatment [19, 20, 34, 59, 65–67, 69, 70, 74, 78, 79, 84].