MANILA (UPDATED) — It took around 3 months for transgender woman "Flora," 22, not her real name, to book an initial appointment at a free trans health clinic in Metro Manila for her to start her physical transition.

And due to the delay in securing a follow-up consultation and worsening "body dysmorphia," Flora sought advice from a community of trans people on the discussion site Reddit by posting her "blood works and other things."

"I don’t want to present feminine nang naka-drag lang. Gusto ko maging feminine presenting on [an] everyday basis," Flora told ABS-CBN News in an interview.

(I don't want to present feminine just in drag. I want to be feminine presenting on an everyday basis.)

Flora has been on gender-affirming hormone therapy (GAHT) for nearly 9 months now without the guidance of a medical professional, which can expose her to health risks. But she plans to see an endocrinologist when she has enough money and is able to maintain consultations.

"Personally, bilang lang sa kamay ko ‘yung kilala kong may endocrinologist," she said. "Ang dami kong trans sisters. Bilang lang sa kamay ko ‘yung may guidance ng doctor. And may guidance sila ng doctor kasi nakakaluwag-luwag sila sa buhay."

(Personally, I could only count with my hands the ones I know who have an endocrinologist. I have many trans sisters. Only a handful of them have a doctor's guidance. And they have the guidance of a doctor because they are well-off.)

Bernadette Neri, who teaches gender studies at the University of the Philippines Diliman, said transgender people undergo transitioning — such as psychological, sociological, legal, and physical — to affirm the gender they identify with, as their sex assigned at birth does not match with their gender identity or expression.

Physical transitioning includes sex affirmation surgery and/or GAHT. Under GAHT, trans women are prescribed estrogen and anti-androgen, while trans men use testosterone therapy.

LONGSTANDING CONCERN

"Do-it-yourself" or DIY hormone therapy, including contraceptive pills that contain estrogen, has been a longstanding concern among the transgender community, especially for trans women, according to Jaya Leonardo Jaud, the vice chairperson for Mindanao of LakanBini Advocates Pilipinas, Inc., a nationwide organization that represents the trans community in the Philippines.

"Sana ma-address 'yan kasi ang tagal na ng panahon nakikita naman ng community … we’re into that (self-medication). Kaso hindi talaga siya naa-address kasi walang batas talaga that would support transgender health," she said.

(I hope that will be addressed because the community has been doing it for a long time... we're into that [self-medication]. But it's not being addressed because there is no law that would support transgender health.)

The internet is also awash with illicit pharmacies that sell hormone pills, Jaud noted. "Nakakatakot, especially for our trans youth. Nagkalat, naglipana ‘yung hormones, kanya-kanya silang dosing ng sarili nila," she said.

(It's scary, especially for our trans youth. The hormones are prevalent, and they are deciding on their own dosing.)

The hormone drugs are "very accessible," Flora said, "in a sense na you can buy" them on e-commerce sites. But they’re not reliable, she cautioned.

"Kasi baka mamaya mga counterfeit products lang naman ‘yun. And at the same time, kung tamang dosage ba talaga ‘yung iniinom mo. And at the same time, mahal siya," she said.

(Because maybe those are just counterfeit products. And at the same time, if it’s the right dosage. And at the same time, it’s expensive.)

Doing hormone transition without the guidance of a doctor can put Flora and many other trans people at a "higher risk" of developing adverse events, said Dr. Harold Henrison Chiu, an endocrinologist and diplomate with the Philippine College of Endocrinology, Diabetes and Metabolism (PCEDM).

"From a medical standpoint, it's best if our patients who want to undergo transitioning consult [e]ndocrinologists … First for proper baseline evaluation of coexisting illnesses, guidance on dosing and education about adverse effects, proper treatment monitoring, and prompt referrals to other medical specialties for co-management," Chiu said.

He noted that their hormone levels need to be closely monitored.

The PCEDM also cautioned against the use of contraceptive pills with estrogen, emphasizing that it is not being used for the transitioning process. Trans women who use contraceptive pills can experience side effects such as deep vein thrombosis or blood clotting in the leg, it warned.

Food and Drug Administration Director General Samuel Zacate urged the public not to use hormone drugs without a doctor's prescription and not intended for their purpose.

"Kung saka-sakali pong gamitin nila outside that coverage, there’s a risk. Kawawa naman po kayo kapag po ginawa n'yo 'yun na hindi naman para doon. Any drug product has a benefit and risk. Ako pinapanawagan ko ang publiko na huwag na po ninyo gawin 'yun kasi mapapahamak lang po ang (inyong katawan)," Zacate said when asked for comment on the prevalence of self-treatment using hormones for medical transitioning.

(If they happen to use outside that coverage, there's a risk. One's health could be compromised when you do that which is not meant for that. Any drug product has a benefit and risk. I am calling on the public not to do that because it will only harm your body.)

LIMITED ACCESS

Yanyan Araña, who handles the trans-related advocacy of the community sexual health clinic Love Yourself Inc., told ABS-CBN News that the majority of transitioning services in the Philippines are led by private institutions.

Although in 2021, the Philippine General Hospital Department of Obstetrics and Gynecology launched its Division of Sexual Health. One of its objectives is to promote trans health care, including the "management of morbidities related to the side effects of patients who underwent gender-affirming treatments."

To respond to the apparent lack of trans health clinics in the country, Araña said her organization, in 2016, put up Victoria by Love Yourself Inc., said to be the first community center in the country that gives trans-focused services. In 2018, the group opened its second trans center, Lily by Love Yourself Inc., which is located in Parañaque.

Yet Araña herself acknowledges that the two clinics of Love Yourself are not enough to cater to hundreds of transgender people, probably more, who wait weeks, or even months, to book a free appointment from their "limited" number of doctors.

But the group, she said, tries to augment its trans services by partnering with local communities and helping them "adapt trans health in their own centers."

"Right now we support 33 organizations all over the Philippines. And we're trying to not only provide sexual health to them but also trans health na din," she said.

Neri, the gender studies professor, noted that limited trans health care has led trans people to look for other ways to do the physical transition.

"Iba’t iba ‘yung kaso pero common talaga na struggle ‘yung pera kasi mahal ‘yung gastos, at nagmamahal dahil hindi siya parte ng healthcare system natin. Mas ganoon ‘yung nangyayari kasi hindi siya bahagi at hindi supportive ‘yung ating healthcare system sa ganitong proseso,” she said.

(There are different cases, but money is a common struggle because of the expensive cost. And the cost is increasing because of our healthcare system. It's not included in our healthcare system, which is not supportive of this process.)

She underscored that physical transition is still taboo in Filipino culture, which she said is dominated by religion.

“Mayroong mga pag-unlad pero nananatili pa rin ‘yung naging impluwensiya sa atin pagdating sa usapin na dalawa lang ‘yung tipikal na nilikha at... dapat hindi mo mabago. Doon papasok ‘yung hindi mo pwedeng baguhin ang iyong katawan kasi ‘yun ay biyaya kahit na magsa-struggle ka pa riyan ang sasabihin pa rin sa 'yo ay kasalanan ‘yan," Neri said.

(There has been progress, but the influence is still there that there are only two typical creations and we must not change what God has created. That's where the idea that you cannot change your body comes in, because it's a blessing. Even if you're struggling, you will be told that it's a sin to change.)

"‘Yun nga ‘yung gusto nating maayos, mawala, na ang ispiritwalidad ay hiwalay doon sa ideya ng relihiyon, at ang relihiyon, siya ‘yung nag-iimpose kumbaga ng mga katakdaan na ito," she said.

(That's what we want to fix, to get rid of, that spirituality is separate from the idea of religion, and that religion is the one that imposes these tenets.)

'INSTITUTIONALIZE TRANS CARE'

Trans advocates, including Araña and Jaud, the leader from LakanBini Advocates Pilipinas, have been campaigning to institutionalize trans health services in the country's healthcare system to address problems such as self-treatment and costly transition care.

"[I]t would be better na ma-institutionalize on a national level in order for it to be more accessible and affordable din as well," Araña said.

In November 2022, the Philippine Professional Association for Transgender Health (PPATH) was established with the aim to institutionalize the needs of the trans community in the Philippines, she said.

According to a report, PPATH has urged the government to "incorporate 'mainstream packages of health services for transgender individuals' in the Philippine Health Insurance Corp. (PhilHealth)."

The group said on its website that transgender people have been "struggling to access inclusive healthcare for their gender-affirming care including hormone therapy and surgery," adding that there is a "challenge among healthcare providers for lacking the competency since transgender-related health is not part of the current academic curriculum or existing specialty training."

"PPATH’s mission is to promote and deliver individualized care for transgender and gender-diverse people, develop responsive policies based on evidence and documented best practices, and foster research, innovation, and collaboration," it said.

Araña, who is also part of the PPATH, said that there were "positive" responses from the government on the establishment of public trans health clinics, especially at the local level. What needs to be done is to amplify the clamor, she said.

"Kailangan, I guess, mas paibayuhin ‘yung voices natin para mas makalampag natin ‘yung puso ng national government, na 'Uy, kailangan din ng vulnerable community itong set of services,'" said Araña.

The Department of Health did not give a statement following repeated requests for comment on the issue of trans health mentioned in this story. This article will be updated once it issues a statement.

But Araña says that trans legislation might not be a priority for lawmakers, pointing out that the SOGIE Equality Bill has been languishing in Congress for years.

"I mean, if you look at SOGIE bill, it’s been like 2 decades or more already and makikita mo ‘yung focus and priority ng government in passing that, then what more pa kaya itong trans health? Which is, in reality, in the LGBT community, we’re under the minority of the LGBT ‘di ba," she said.

"So, I guess, a lengthy process pa. But hopefully in the upcoming years, ma-prioritize na siya. Kasi it's a need talaga, kasi you know naman it's a basic human right for the trans community to access health care services," she added.

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Despite her struggles in transitioning, one thing’s certain for Flora, that she is, indeed, a trans woman.

"Ako gusto ko lang talaga (mag-transition) kasi gusto ko maging female presenting but you can identify yourself as a trans woman even though you’re not taking meds. Even though you have bigger biceps compared sa typical woman, even though bato-bato ka, babae ka pa rin," she said.

(I just really want to [transition] because I want to be female presenting but you can identify yourself as a trans woman even though you're not taking meds. Even though you have bigger biceps compared to the typical woman, even though you are muscular, you are still a woman.)

"If I have a choice na maging lalaki na lang, I will but no. Kasi hindi naman ako lalaki in the first place, babae ako."

(If I have a choice to just be a man, I will but no. Because I'm not a man in the first place, I'm a woman.)

— with a report from Willard Cheng, ABS-CBN News

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