Exploring the barriers and enablers of oral health care utilization and safe oral sex behaviour among Transgender women of Malaysia: a qualitative study

Background: Transgender women in Malaysia are vulnerable and marginalized. They experience unique social and interpersonal challenges that contribute to relatively unmet health care needs thereby increasing their risk of acquiring HIV and sexually transmitted infections (STIs). With research pertaining to oral health of transgender women being sparse in literature, this study aimed to understand their experiences by exploring the barriers and enablers of oral health care utilization as well as safe sexual behaviour relating to oral transmission of STIs among Transgender women. Methods: Semi structured in-depth interviews (n=20) with a group of urban dwelling transgender women (mean age= 39.8 years) in Northern Malaysia and Focus group discussion (n=7) with key informants was conducted to gain insights into the needs of the community. Participants were recruited through a snow-balling method of sampling with the help of transgender women community workers. The data obtained was coded and transcribed and subjected to thematic analysis to interpret and derive major themes and subthemes. Community advocates were involved in planning of the study. Results: All of participants reported experiencing high levels of stigma and discrimination in daily life. Routine engagement in oral sex practices (100%, n=20) was reported with multiple partners (60%, n=12) with a perceived low level of risk of transmission of STIs through this practice (80%, n=16). Nighty percent (n=18) never used barriers or inconsistently used them during oral sexual practices. Additionally, low utilization of dental services was reported with 80% (n=16) not having visited a dentist in the past 12 months or seeking self-medication or unprofessional care. The themes that emerged from the qualitative analysis were key to understanding the experiences of the community. Conclusion: The results identified gaps in awareness of oral transmission of STIs among the transgender women. The importance of social support in positively influencing health promotion as well as improving health care and dental care utilization was highlighted. The development of an educational intervention is proposed as an instrument to address these gaps and provide support. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study received ethics approval by the University College Dublin, UCD Human Research Ethics Committee Sciences (HREC-LS) (LS-C-22-158-Telang-Cotter) and the Joint Penang Independent Ethics Committee (JPEC 22-0002) I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript