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International Journal of Healthcare Management
ISSN: 2047-9700 (Print) 2047-9719 (Online) Journal homepage: http://www.tandfonline.com/loi/yjhm20
Factors influencing selection of medical tourism
destinations: A special niche market
Azim Zarei, Davood Feiz, Morteza Maleki Minbashrazgah & Fatemeh Maleki
To cite this article: Azim Zarei, Davood Feiz, Morteza Maleki Minbashrazgah & Fatemeh Maleki
(2018): Factors influencing selection of medical tourism destinations: A special niche market,
International Journal of Healthcare Management, DOI: 10.1080/20479700.2018.1492764
To link to this article: https://doi.org/10.1080/20479700.2018.1492764
Published online: 10 Jul 2018.
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Factors influencing selection of medical tourism destinations: A special niche
market
Azim Zarei, Davood Feiz, Morteza Maleki Minbashrazgah and Fatemeh Maleki
Faculty of Economic, Management & Administrative Sciences, Semnan University, Semnan, Iran
ABSTRACT
Some studies have focused on identifying the factors affecting the selection of medical tourism
destinations with regard to different types of treatment. But less attention has been paid to
factors affecting individuals’travels to Iran for sex reassignment surgeries (SRS). There is a
research gap with regard to this niche medical tourism market in Iran. Iran is one of the SRS
pioneer countries, where the concept of this medical tourism market can be developed
further. This study addresses this knowledge gap through in-depth interviews with key
professionals in SRS and medical tourism. We use a content analysis of interviews to identify
the factors affecting the selection of Iran as a medical destination for SRS by individuals. The
results indicate that factors influencing individuals’decisions on medical tourism destinations
come under seven headings. We conclude by recommending research directions for future
research by health, medical, and managing scientists.
ARTICLE HISTORY
Received 7 April 2018
Accepted 18 June 2018
KEYWORDS
Developing countries;
medical tourism; medical
tourism marketing; medical
travel; sex reassignment
surgery; transgender
Introduction
Traveling from developing countries to developed and
rich ones for medical services was the usual phenom-
enon for wealthy people in the past. This trend has
recently been reversed and people from developed
countries travel to developing ones and even Third
World countries for medical services, for personal or
cost reasons [1–4]. Owing to the high costs, people
are likely to seek affordable medical services in foreign
countries –and most probably in developing ones. One
of the financial issues is the lack of health insurance
compensation for some expenses of medical services
in developed countries [2,3,5]. Medical tourists are
motivated by intrinsic factors (known in the industry
as inbound medical tourists and extrinsic (are known
in the industry as outbound). Some Asian countries,
with a high quality of medical services and low prices
compared to other medical tourism destinations,
have attained a remarkable position in the medical
tourism market [2,6,7]. According to the development
of communication tools and information-sharing and
traveling facilities, finding and consulting a doctor in
a foreign country and traveling to that country do
not comprise a difficult process [8]. In the recently
growing medical tourism industry, having an appropri-
ate marketing strategy can help countries find their fair
positions [9]. Some studies have investigated some
types of medical tourism markets, including reproduc-
tion, cosmetic surgery, heart surgery, knee/hip
replacements, dental services, and maternity tourism
[1,6,10–16]. However, the sex reassignment surgeries
(SRS) tourism market has been neglected as a growing
tourism market, except in a few studies [17,18].
Chuang et al. [19] revealed that just 0.26% of medical
tourism studies had discussed SRS compared to
organ transplantation (26.53%), stem cells (9.69%),
cosmetic (4.08%), reproductive (4.08%), and dental
(2.81%). In the late 1980s, in Iran –as a Shiite-majority
Muslim country –SRS was legalized in Shari’a and in
state law by the Fatwas of Ayatollah Khomeini. Till
2008, after Thailand, Iran had the largest number of
SRS operations in the world [20]. Nevertheless, consid-
ering Iran as a pioneer SRS country, there is a research
gap about this niche medical tourism market in Iran.
When a researcher intends to first identify the variables
of such a phenomenon, he/she needs to use qualitative
methods [21]. In this study, we are going to naturally
identify factors affecting the choice of individuals of
Iran as an SRS tourism destination, using the qualitat-
ive method.
A special medical tourism niche market
SRS is a surgical procedure in which a person’s physical
appearance and functions of their born sexual charac-
teristics change to that of the other gender. People may
pursue SRS for two reasons. A group may be born with
intersex deformities in their sex organs, which they
need assign to either the male or female sex. The
other group is who feel trapped in wrong bodies and
may decide to change the bodies they are born into
other sex. The issuance of legal permissions for SRS
© 2018 Informa UK Limited, trading as Taylor & Francis Group
CONTACT Azim Zarei a_zarei@semnan.ac.ir Faculty of Economic, Management & Administrative Sciences, Semnan University, Semnan Zip Code:
35131-19111, Iran
INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT
https://doi.org/10.1080/20479700.2018.1492764
began in Iran from 1967 by Ayatollah Khomeini’s
Fatwa [22]. After Thailand, Iran has provided leader-
ship to legitimize gender reassignment surgeries
(GRS). In Iran, people after the diagnosis of transgen-
derism, are legally permitted hormone therapy and
GRS [20]. After GRS, all their identity documents are
changed in accordance with their new sex. Bucar and
Enke [20] refer to Tehran as a salient center for SRS.
GRS records in Iran demonstrate experience and
expertize of the surgeons [23,24]. In recent years, the
numbers of GRS medical tourists –especially from
countries in close proximity –have increased. Different
countries have different acceptance levels for SRS. Even
countries with a similar religion have different perspec-
tives, in accordance with their attitudes [25]. Thus, Iran
–as a Muslim country –can be a significant destination
for SRS Muslim medical tourists.
Research methodology
A qualitative approach was used to investigate the fac-
tors affecting SRS medical tourism in Iran. We used
purposive sampling in accordance with specific criteria
that guarantee the quality and relevance of the partici-
pants [26]. Our study focused on elective SRS doctors,
surgeons, and medical tourism researchers with
enough information about SRS in Iran. Moreover, the
marketer specialists needed to have enough infor-
mation about SRS under the relevant rules and medical
tourism. The surgeons and doctors had to be engaged
in the provision of SRS services for at least five years.
To be eligible, surgeons had to have the experience of
encounter with foreign tourists that travel to Iran
(see Table 1). Interviews were conducted over a period
of three months in Iran. In-depth face-to-face inter-
views took place with five surgeons and doctors and
two marketing specialists, who were selected because
of their status as knowledgeable respondents. Accord-
ing to the mentioned criteria, three marketing special-
ists were identified in Tehran that one of them was not
available. Moreover, eight surgeons and doctors were
identified in Tehran that three of them were not avail-
able. The characteristics of participations are listed in
Table 1(see Table 1).
The interviews were performed in a hospital, clinic,
or respondents’offices. The interviews were recorded
and transcribed verbatim except for one of them, in
which permission was not given to record the inter-
view, and notes were taken. Each interview lasted
Table 1. Characteristics of participants.
Num Informants Experience Gender Age
D1 Marketer specialist More than 10 years of
tourism research
Male 48
D2 Urologist and SRS
surgeon
More than 20 years of
SRS experience
Male 58
D3 General surgeon More than five years
of SRS experience
Female 40
D4 General surgeon with
SRS expertize
More than 30 years of
SRS experience
Male 69
D5 Marketer specialist More than five years
of tourism research
Male 42
D6 General practitioner and
PhD in Psychology of
Sexology
More than five years
of transgender
research
Male 49
D7 Psychiatrist More than 20 years of
transgender
research
Male 58
Table 2. The coding scheme.
Categories Units of meaning/open codes
Religious similarities Religious similarities
Shia Muslims
Non-Shi’a Muslims
Religious prohibition in the
home country
Prohibition of some surgeries in some
countries
Religious permission in the
destination country
Religious permission
Sharia and Fatwas
Enforcement of religious laws Halal food and Hijab
Certainty in observance of religious
rules
Religious beliefs
Quality and standards of
medical services
High quality of surgeries
The large number of SRS in Iran
Experience and expertize of doctors
Medical equipment
Marketing and advertising
channels
Medical or social conferences
Introducing and advertising by the
media
Doctor’s reputation
Stability and security Feeling secure in the destination
country
Political relations with the destination
country
Economic stability
Familiarity with destination
country
Familiarity with Iran
Destination country recognition
Familiarity with language and culture
Travel risk
Cultural adaptation at destination in
accordance with the SRS services
Affordable costs The low cost of SRS in Iran
Low cost of travel to Iran
Rules and regulations Rules and regulations for SRS in Iran
No need for special legal permits for
foreign patients
Legality of SRS in Iran
Services provided by the doctors Choice of destination caused by global
reference
Results and evidence of surgeries
Post-operative services
Consultation with a doctor
Comfort of travel Comfort of travel to Iran
Visa facilities
Accommodation and welfare facilities
The distance between home
country and destination
country
Geographic proximity
Neighboring countries
Limitations of medical services Restrictions on medical services in the
home country
Low quality of surgeries in the home
country
Legal prohibition of SRS in the home
country
Economic constraints Lack of health insurance compensation
in home country
The high costs of SRS in the home
country
Anonymity of treatment
received abroad
Patient’s desire for privacy of surgeries
Reduction in mental stress as a result of
anonymity in destination country
Reduction in social pressure as a result
of anonymity in the destination
country
2A. ZAREI ET AL.
around one hour. We have utilized qualitative content
analysis to explore factors affecting SRS medical tour-
ists’travels to Iran. All the transcribed interviews
were imported into MAXQDA 12. The initial coding
was done by the team of authors (including four per-
sons) and each of them carefully read the interviews
and notes, comments, and memos, written in the pro-
cess of data analysis, to provide a better understanding
of the themes that emerged [27]. In this study for
reliability and validity, the researchers have investi-
gated credibility, transferability, dependability, and
conformability through reflexivity, triangulation, inter-
view technique, structural coherence, dense descrip-
tion, dependability audit, stepwise replication, and
code-recode procedure [28,29]. First, significant state-
ments based on participants’experiences were coded
into units of meaning, or in vivo nodes. Overlapping
or redundant units were related and categorized into
46 open codes (see Table 2). Second, connections
between the initial 46 codes were sorted into 16 cat-
egories. Categories and initial codes are in Table 2.
Findings
Through the coding of the interviews, seven main con-
ceptual themes can be identified, which characterize
SRS medical travels: Religion, quality and standards
of medical services, marketing, and advertising chan-
nels, Iran’s attractiveness for SRS, services provided
by the doctors, and restrictions on receiving medical
services at home. Iran’s attractiveness for SRS including
rules and regulations and familiarity with destination
country were most cited by participants. The second
place is dedicated to restrictions on receiving medical
services at home. Restrictions on receiving medical ser-
vices at home and rules and regulations were more
prevalent by doctors and surgeons. Moreover, comfort
of travel and familiarity with destination country were
more prevalent by medical tourism marketer
specialists.
Religion
Sometimes medical tourists select a foreign country for
the sake of cultural or religious expectations [30].
People –in particular religious people –prefer to travel
for medical services to countries that have a similar
religion and culture. In countries with a similar reli-
gion, the followers of that religion feel safer about the
observance of religious rules. Shiite Muslims choose
Iran for SRS due to religious similarities, religious
beliefs, or for reassurance regarding the implemen-
tation of the religious law. Also, non-Shi’a Muslims
may choose Iran to feel safe in terms of religious
laws, especially general rules like hijab and halal food.
Participants stated:
…Owing to its religious and geographic proximity,
Iran is a great option for GRS medical tourists from
those Muslim countries [D3].
…Non-Shi’a Muslims choose Iran for hijab or halal
food, or the sense of security in respect of religious
laws in the destination country and the Iranian medi-
cal staff[D1].
Moreover, some medical tourists select Iran because of
the religious prohibitions in their respective home
countries. Participants stated:
In some countries, their religion and their religious laws
are the biggest obstacle for GRS …In some Muslim
countries, after SRS sometimes, they live in another
country with supportive laws …Individuals with
different religions have different perspectives about
GRS and react differently to these operations [D2].
Quality and standards of medical services
Perceived quality has been mentioned as a primary fac-
tor searched by potential medical tourists [30,31], inso-
far as in some cases, the importance of quality can justify
the price premium. Perceived quality and medical ser-
vice standards contain medical equipment, technology,
surgical/medical skills, or the reputation of countries
and doctors seen as pioneers in their field of expertize
[32]. Iranian surgeons have attained remarkable experi-
ence, since Iran is a pioneer in SRS. Non-Muslims who
choose Iran for non-religious purposes did so because of
the high quality of medical services, along with the
reasonable prices. Participants stated:
This surgery is performed in our country in accord-
ance with the high standards with high facilities and
medical equipment, at a much lower cost [D4].
…This affects the quality of the operations and the
doctors are experienced; just a few doctors do this
operation outside Iran, which means that the quality
of the operations is acceptable [D3].
Marketing and advertising channels
When individuals decide to travel abroad to avail medi-
cal services, they try to take the best possible decision.
SRS medical tourists try to choose the best destination
in accordance with the quality of medical services.
Heung et al. [21] have shown that medical tourists
are likely to use advertising and distribution channels
as the first steps. Potential medical travelers can seek
medical services’quality, prices, and other clients’com-
ments on websites [33,34]. So, potential tourists for
SRS definitely investigate all options available in poss-
ible destinations for such an important surgery. They
obtain information from medical or social conferences,
the media, or the internet. As medical services are
intangible products that cannot be tested before pur-
chase, individuals who seek medical services in a
INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 3
foreign country can be affected by a doctor’s repu-
tation. This fame can be gain by satisfied previous cli-
ents [35]. The satisfied client promotes his/her
satisfaction through media, resulting in a boost to the
doctor’s reputation. Participants stated:
Organizations that can carry out marketing and medi-
cal activities have a great impact on Iran’s recognition
by SRS medical tourists [D3].
Medical or social conferences which discuss the ser-
vices required for the GRS can be an important factor
for the reason why GRS medical tourists chooses Iran
[D1].
Iran’s attraction for SRS
Iran’s attractiveness for SRS as a pioneer for such medi-
cal services includes affordable costs, rules and regu-
lations, stability and security, and familiarity for
countries in close proximity. When deciding to receive
medical services beyond the borders of the home
country, familiarity can be an effective factor, so border
countries are prioritized. Medical procedures per-
formed at home carry an element of risk [36], p.22. Tra-
veling to a foreign country intensifies the feeling of risk
and selecting a border country (familiarity with cultures
and close distance between home country and destina-
tion) help reduce this risk. Hence, popular medical tour-
ism destinations are often selected by people for their
proximity [37]. This is due to the distance between the
home country and the destination country. Moreover,
the influences of familiarity on the selection of the des-
tination can be caused by the fact that similar religious
beliefs or culture are sought [30]. Also, the legal frame-
work and regulatory policies is a factor that affects medi-
cal tourism [38]. For SRS –on which different countries
have different perspectives –legality is an important fac-
tor. Moreover, affordable costs in Iran are a salient factor
for SRS medical tourists. Iran, in the region, also has
greater relative stability compared to the surrounding
countries and this stability can influence potential medi-
cal tourists. Participants stated:
Relations between countries and the type and degree
of proximity and political relations of countries are
factors that influence the choice of countries as desti-
nations of medical tourism [D5].
The proximity and geographical closeness that gener-
ate cultural, ethnic, and linguistic proximity can be
effective in choosing a medical tourism destination.
Also, geographic proximity helps (one) …to become
more aware of the surrounding countries, thereby
leading to less risk aversion when traveling, and
fewer fears and fewer psychological risks [D1].
Services provided by the doctors
According to the long of SRS has been legitimated in
Iran, experienced doctors and surgeons, some of
whom have licenses from developed countries, guaran-
tees the quality of SRS in Iran. Moreover, well-trained
and experienced doctors, who can speak potential
medical tourists’language and provide consulting ser-
vices, are an attractive factor in medical tourism desti-
nations [21,30]. In a special case like SRS, the expertize
of the surgeon is an important factor for potential
medical tourists. Also, proactive services provided by
doctors enhance the quality of surgeries. Participants
stated:
The results of the large number of operations that has
been carried out have become a database that guaran-
tees the reliability of my surgical procedure and the
quality of the operations [D2].
Ease of travel and stay
Comfortable travel and the distance between the home
country and destination influence SRS medical tourists’
selection of Iran as a destination. Travel essentials for
the destination country, such as visas and the transpor-
tation system, are factors that influence the decision to
travel to a foreign country [21]. Moreover, comfortable
accommodation in destinations and the availability of
accurate information for reservations is a significant
factor for the individual who decides to travel to a
foreign country to receive medical services [39]. The
selection of a border country will make medical travel
easier, since tourists can gain more accurate infor-
mation and reduce financial and non-financial risk.
Participants stated:
…Legislative factors include visas, length of stay, and
ease of travel and accommodation in Iran to attract
tourists [D1].
After the operation, these people need to stay in Iran
for a while; in addition to hospitals, they can stay in
hotels …[D4].
Restrictions on availing medical services at
home
Eugene [40] noted that medical tourists’travels from
their respective home countries can be caused by the
lack of medical services in the home country or pro-
blems in the home country’s medical systems, such as
high costs, uninsured procedures, or unavailability of
healthcare services. When the prices of medical services
are high, they seek their desired services in accordance
with the acceptable quality in developing countries.
Owing to the high prices of SRS in developed countries,
low-cost medical services in Iran can be an attractive
factor when compared to other Asian countries. More-
over, when a special medical service is denied in the
home country, individuals who face legal prohibitions
are motivated to cross the border to receive those ser-
vices in a foreign country [36], p.23, [41]. According to
4A. ZAREI ET AL.
the different levels of acceptance of SRS in different
countries, medical tourists seek destinations with
legal permissions. Moreover, some medical tourists
select Iran because of their desire for privacy, as,
through this privacy, they feel less mental or social
pressure. Participants stated:
…Since GRS costs are not covered under health insur-
ance in some developed countries, the costs of surgery
in Iran are much more affordable for them [D6].
…Iran is selected as a foreign country because of its
anonymity, and this anonymity reduces the psycho-
logical pressure on the person [D4].
Discussion
This work aimed to understand medical tourism
attraction factors in one of the special niche markets,
SRS in Iran. Market segmentation can help focus on
customers and use its maximum potential [42]. In
this research, therefore, we focus on a special medical
market segment. From the interviews with doctors,
surgeons, and specialists, the factors influencing SRS
medical destination selection are characterized as: Reli-
gion, quality and standards of medical services, mar-
keting and advertising channels, Iran’s attraction for
SRS, services provided by the doctors, ease of travel
and stay, and restrictions on receiving medical services
at home. Moghimehfar and Nasr-Esfahani [43] have
shown that legal restrictions and religious issues influ-
ence medical tourists’destination in fertility tourism.
According to SRS doctors and surgeons in Iran, reli-
gious rules and legal and religious forbiddance are
motivators for selecting Iran as an SRS medical destina-
tion. Nisha and Iqbal [44] believe that the young and
large Muslim population across the world needs to per-
ceive products and services in accordance with Islamic
regulations. So, Iran –as a Muslim country –can be a
desirable destination for the SRS Muslim medical
tourist.
Radovcic and Nola [45] have divided tourism medi-
cal risk into several types such as medical risks, legal
risks, and ethical risks. Medical surgeries and especial
SRS ones intrinsically have risk in themselves. Com-
bined with travel risk, people prefer to select a familiar
destination –because countries near their borders have
similar culture and this reduces language barriers and
financial and non-financial risks. As a result, border
countries are reasonable options, known as backyards
[46]. When a desired medical service is especially
inadequate, unavailable, or illegal in the home country,
such as SRS, they seek it in neighboring countries [47].
Potential medical tourists seek health and medical
information and advertising. Iran’s SRS medical tour-
ists obtain information from platforms such as medical
conferences, the media, and word of mouth (WOM).
Internet and online social networks site influence
potential medical tourists through WOM and other cli-
ent experiences and their comments. The results and
evidence of the doctors’previous surgeries can be pro-
vided by the doctors when consulting medical services
in a foreign country. Sometimes SRS medical tourists
choose Iran due to global references, such as valid
scientific articles. Moreover, the quality and the rates
of successful surgeries by experienced surgeons and
well-equipped clinics and hospitals have attracted
SRS medical tourists.
Restrictions, including unavailable medical services,
financial constraints, or the desire for privacy, motivate
people to seek medical services in destination
countries. People prefer a private affair be done in a
foreign country to maintain anonymity because of
the cultural norms of the home country [1]. Some
SRS medical tourists select another country, seeking
anonymity, because their home country has cultural
or legal restrictions. SRS may be domestically prohib-
ited and illegal or have no significant quality. More-
over, high SRS prices in other countries (compared to
Iran) were mentioned by almost all participants. Some-
times, the prices of medical services in developing
countries are one-tenth of developed ones [21]. The
costs of medical services in medical tourism desti-
nations can be a strong motivator in the selection of
destinations [30,32]. The lack of adequate health insur-
ance, which affects some people, is one of the drivers
motivating individuals to seek medical services abroad
[36], p.22.
While this study qualitatively investigates factors
affecting selection Iran as an SRS medical tourism des-
tination, Hanefeld et al. [1] have studied qualitatively
factors affecting medical tourism destination selection
among cosmetic, dental, bariatric, and fertility medical
tourist. According to their study distance, costs, exper-
tize, availability of treatment, and informal networks
affect choice of destination. Moreover, Payne [13]
has investigated reproductive medical travels between
Sweden and the Baltic states. Patients go abroad for
egg donation for the sake of choices such as choosing
destination country, clinics and treatment method.
Aizura [17] have studied foreign female transsexuals’
experience in Thailand hospitals considering the
impact of Buddhist rituals and beliefs. Jaapar et al.
[15] have examined dental tourism as a particular
medical tourism market. They have shown that dental
care quality, dental care information access, and cost-
savings are most important factors affecting choosing
Malaysia as dental tourism destination. Also Moghi-
mehfar and Nasr-Esfahani [43] have investigated fac-
tors affecting selecting Iran as infertility treatment
destination by foreign couples. They have believed
that in addition to general factors including price, dis-
tance, lack of expertize, and tourist attractions, reli-
gion is an important factors affect selecting Iran by
Muslims couples.
INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 5
Conclusions
The results of this study highlight that, factors influen-
cing medical tourists to select Iran as a GRS destination
can be broken down into seven categories: Religion, qual-
ity and standards of medical services, marketing, and
advertising channels, Iran’s attractiveness for SRS, ser-
vices provided by the doctors, ease of travel and stay,
and restrictions on availing medical services at home.
In accordance with Fetscherin and Stephano’s[48]
division of motivating factors for medical tourism
into push and pull groups, we can refer to quality
and standards of medical services, marketing advertis-
ing channels, services provided by the doctors, eases of
travel, and Iran’s attraction as pull factors and restric-
tions on availing medical services at home as push fac-
tors. Religion can play both push and pull roles.
The selection of a medical tourism destination is a
complex process. This process is affected by personal
reasons, such as SRS private, and intimate or general
factors such as unavailability or the prevailing legal fra-
mework in the home country. For people from differ-
ent home countries, different factors have different
effects. For example, socio-cultural factors may be at
the highest level for the selection of the destination
for a religious person, while quality or price may influ-
ence a non-religious person.
Future studies can quantitatively evaluate factors
affecting the selection of medical destinations among
people from different home countries. Moreover, quali-
tative research can be done on the SRS medical tourists,
and its findings can be compared with results from this
study. According to the nature of qualitative research
that answers ‘how’questions [7], more qualitative
studies should be conducted on different countries by
investigating factors for medical tourism travel for
those in specific types of medical markets.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Notes on contributors
Azim Zarei, PhD, is an Associate Professor in systems and
marketing.
Davood Feiz, PhD, is an Associate Professor in Public sector
policy and marketing.
Morteza Maleki Minbashrazgah, PhD, is an Assistant Pro-
fessor in industrial Marketing and Marketing investigation.
Fatemeh Maleki, PhD Candidate, is a researcher in medical
tourism and marketing.
ORCID
Morteza Maleki Minbashrazgah http://orcid.org/0000-
0001-5780-5967
Fatemeh Maleki http://orcid.org/0000-0001-7196-1990
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