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The sex industry, which many kathoey individuals rely on for income, is also fraught with risks and challenges. Sex work is often stigmatized, and those involved may face exploitation, abuse, and violence. Additionally, the industry's reputation can perpetuate negative stereotypes about kathoey individuals, reinforcing the notion that they are solely defined by their involvement in sex work.

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The term "extreme" might also refer to the journey these individuals undertake, both physically and emotionally, to align their appearance and life with their gender identity. For some, this journey includes medical procedures such as hormone therapy and surgeries. For others, it might mean adopting a feminine lifestyle without medical interventions. The sex industry, which many kathoey individuals rely