Available but insecure: Healthcare access and self-managed gender-affirming hormone use among trans women and trans men in Malaysia: A qualitative study

Transgender people in Malaysia may be able to reach public healthcare services, but care is not necessarily safe, acceptable or usable. This qualitative study explored transgender adults’ experiences of stigma, healthcare access, support systems and health-related practices. During analysis, gender-affirming hormone use emerged as a key practice through which minority stress and healthcare access intersected. Self-managed gender-affirming hormone use was defined as using feminising or masculinising hormones without formal prescription or ongoing clinical monitoring, including through pharmacies, peers, online sources or informal advice. Twenty-one transgender adults (18 trans women, 3 trans men; aged 25–55 years) participated in ten individual and four small-group interviews. Data were analysed using theory-informed thematic analysis drawing on the Minority Stress Model and Levesque’s healthcare access framework. Three themes were identified. First, early bullying, family rejection, religious condemnation, anticipated rejection and concealment produced long-term mental strain, while peer networks, community organisations and spiritual reinterpretation supported resilience. Second, healthcare was experienced as available but insecure: low-cost public services existed, but misgendering, legal-name use, documentation barriers, privacy concerns and ward or toilet allocation led to avoidance, delayed care and selective disclosure. Third, participants described gender-affirming hormone use as supporting embodiment, social affirmation and relief from distress, but limited access to respectful, monitored services led many to self-manage hormones without prescription or monitoring, creating preventable risks. Improving transgender healthcare in Malaysia requires making existing services safer and more acceptable through respectful administrative practices, privacy-sensitive clinical encounters, accessible hormone-related support and stronger links between public healthcare and community organisations.