Prevalence of and factors associated with the use of gender-affirming hormonal therapy outside the reference regimen among transgender people in a community-led clinic in Metro Manila, Philippines: a retrospective cross-sectional study

Abstract

Objectives

We aimed to describe the gender-affirming hormonal therapy (GAHT) intake behaviour and regimen and the factors associated with the use of hormones inconsistent with reference GAHT regimen among transgender people in the Philippines.

Design

Cross-sectional study.

Setting

Transgender community clinic in Metro Manila, Philippines from March 2017 to December 2019.

Participants

Gender-affirming care-seeking individuals of at least 18 years old, who self-identified as transgender or non-binary, and who self-reported current or previous use of GAHT at baseline consult.

Primary outcome measures

Reported drugs and/or administration routes not congruent with the World Professional Association for Transgender Health Standard of Care eighth edition were classified as hormone use outside the reference regimen.

Results

253 transgender people reported current or previous intake of GAHT. Many trans women and transfeminine people (TWTFP; 58.9%, 86/146) reported using oral contraceptive pills (OCPs), whereas most trans men (TM; 73.8%, 79/107) reported injecting testosterone esters. Furthermore, 59.7% (151/253) used hormones outside the reference regimen, widely using OCP and anabolic steroids among TWTFP and TM, respectively. TWTFP (crude prevalence ratio, PR, 3.52; 95% CI 2.35 to 5.49) and those who take unprescribed GAHT (crude PR 2.37; 95% CI 1.08 to 6.68) were more likely to use hormones outside the reference regimen than TM and taking healthcare provider-prescribed GAHT, respectively. On adjusting for covariates, the prevalence of using hormones outside the reference regimen was approximately three times higher (adjusted PR 3.22; 95% CI 2.09 to 5.12) among TWTFP than TM.

Conclusion

Trans people act on their high unmet gender-affirming care needs by taking unprescribed GAHT, many outside the reference regimen. Structural changes in the health system are warranted, including strengthened community-based self-administration practices.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study is the first to provide information on gender-affirming hormonal therapy (GAHT) intake behaviours and regimens among trans men, trans women, and non-binary people in the Philippines. It could help improve the health system’s response to their unmet GAHT needs.

• Missing and uncollected data limited the secondary analysis nature of the study, and its cross-sectional design precluded insights into causality.

• Gender-affirming care-seeking trans people are more likely to access the community clinic, which could lead to selection bias.

Background

Transgender or trans people are a diverse group of individuals whose gender identities or expressions are different from what is expected of the sex they were assigned at birth.¹ In 2022, an estimated 205 000 trans women (TW) 15–49 years of age were reported in the Philippines.² However, there are no population estimates for trans men (TM). Being part of a minority situates transgender people under an insurmountable amount of stress from gender-based stigma and discrimination which could exacerbate their gender dysphoria and perpetuate health disparities.³

Access to gender-affirming care promotes the overall health and quality of life of trans people, especially among those with gender dysphoria.⁴ Gender-affirming care needs are diverse and individualised, and utilisation depends on accessibility and resources. Gender-affirming hormonal therapy (GAHT) is often the primary or sole form of gender-affirming care among trans people,⁵ not only because it is effective in changing secondary sex characteristics but is also more affordable and accessible relative to gender-affirming surgery/procedures (GASP).⁵ Among the TW surveyed (n=1225) in the Philippines’ 2018 Integrated HIV Behavioural and Serologic Surveillance, 33% took feminising hormonal pills and 17% injected hormones.⁶ Among gender-affirming care-seeking trans people in a community-based clinic in Metro Manila, almost half were already on GAHT at baseline consult, 93% of whom were administering hormones without prescription.⁷ By and large, these indicate a lack of accessibility to GAHT in the Philippines.

Community-led clinics by non-profit organisations provide access to GAHT among trans people in the Philippines.⁸ Victoria by LoveYourself (VLY) is the Philippines’ first trans-specific health centre and was established in 2016 by LoveYourself, an Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex, Asexual (LGBTQIA+) community-based non-profit organisation. Located in Metro Manila, VLY provides a one-stop shop integrated trans health and sexual health services to trans people coming from within and outside Metro Manila. Peer providers and most licensed healthcare practitioners come from the LGBTQIA+ community and primarily identify as trans. Free gender-affirming care services include sexual orientation, gender identity and expression, and sexual characteristics (SOGIESC) and transition counselling, GAHT consultation, and presurgical assessment and referral for GASP. The clinic is self-funded by LoveYourself, with assistance from multiple donor funding.

Apart from optimising clinical benefits, medical supervision for GAHT also prevents adverse outcomes, some life-threatening, such as polycythaemia from masculinising hormones and cerebral and cardiovascular complications from feminising hormones.^{4 9} However, the lack of studies on GAHT regimen and intake behaviour among trans people and the lack of local guidelines on GAHT in the Philippines preclude clinicians’ awareness and competency on GAHT.^{8 10 11} The Philippines Department of Health has not yet endorsed any guidelines for GAHT, but more guidelines from different institutions outside the country have been available in recent years. Some broadly used guidelines are based on clinical experiences from high-income countries (HICs) and predominantly non-Asian populations,^{1 12 13} which raise issues of applicability in low-income and middle-income countries (LMICs) in Asia, such as the Philippines.¹ There are two recently disseminated guidelines from Asia Pacific.^{14 15} The guidelines developed in Thailand have strong underpinnings on Asian clinical practice and culture.¹⁵ Nonetheless, the World Professional Association for Transgender Health’s Standard of Care eighth Edition (WPATH-SOC8) was developed with a more global perspective and scope.¹ WPATH-SOC8 recommends the following feminising hormones: (A) oestrogen, including oestradiol valerate or hemihydrate oral, and/or oestradiol valerate or cypionate injectable, and/or oestradiol transdermal gel or patch and (B) if with testes, testosterone-lowering drugs, including spironolactone oral, cyproterone acerate oral or gonadotropin-releasing hormone (GnRH) agonist injectable. Whereas testosterone enanthate, cypionate or undecanoate injectables and/or testosterone transdermal gel or patch are recommended for masculinising hormones. WPATH-SOC8 recommends against using ethinyl forms of estradiol,¹ commonly a component of oral contraceptive pills (OCPs) widely used for GAHT in the Philippines.⁸

No other studies in the Philippines describe GAHT regimens and intake behaviour of trans people apart from case studies^{11 16} and a qualitative study among TW living with HIV.¹⁰ Owing to these gaps, the study aimed to describe the GAHT intake behaviour and regimen and the factors associated with the use of hormone inconsistent with reference GAHT regimen among trans people in Metro Manila, Philippines. Results from the study could help improve clinical practice and pharmaceutical regulatory policies to facilitate accessibility to GAHT and improve gender-affirming care in the Philippines.

Methods

Study design and setting

We conducted a single-centre cross-sectional study among trans people seeking gender-affirming care in VLY. Information on VLY, particularly its service delivery model, is described above. We reviewed baseline consult medical records of patients and extracted routinely collected clinical data, particularly on GAHT intake. We used the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist to guide the conduct and reporting of our analysis.¹⁷

Study participants

Using convenience sampling, all patients in VLY who enrolled from March 2017 to December 2019, who were at least 18 years old, who self-identified as transgender or non-binary, and who currently or previously used GAHT at baseline consult were included as study participants.

Data collection

During the baseline consult, counselling on SOGIESC with trans peer providers was undertaken by health-seeking individuals. Licenced nurses and physicians performed medical history and physical examination and recorded information, including sociodemographic profile, gender, gender dysphoria, GAHT intake (prescription and regimen) and GASP (procedures done and desired), using a standardised medical assessment form (online supplemental table 1). All providers were trained for gender-affirming care based on the standards and principles of care recommended by WPATH.¹

Outcome assessment

Among patients who reported current and previous GAHT use at baseline consult, we extracted the drug and administration route of the most recent regimen used for gender affirmation (online supplemental table 1). Additionally, we identified patients who reported using drugs and/or administration routes that were not congruent with the aforementioned WPATH-SOC8 recommendations¹ and assigned them as reported hormone use outside the reference regimen. Otherwise, if both the drug and administration route were consistent with the recommendations, we assigned these patients as reported hormone use in accordance with the reference regimen.⁹

Limited drugs among the reference regimen are available in the Philippines, including oestradiol valerate oral, oestradiol hemihydrate oral, oestradiol hemihydrate gel, cyproterone acetate oral, spironolactone oral, testosterone enanthate parenteral and testosterone undecanoate parenteral,¹⁸ and none of these are approved for gender affirmation in the Philippines. The rest are obtained from peers, online or overseas.⁸

Patient characteristics assessment

For the sociodemographic variables, the age in years, location of residence, sex assigned at birth, gender identity and current employment status were extracted. Gender dysphoria was dimensionally measured using the Gender Identity/Gender Dysphoria Questionnaire for Adults and Adolescents scale¹⁹ and was clinically diagnosed using the Diagnostic and Statistical Manual for Mental Disorders fifth Edition.²⁰ Whether or not a medical provider prescribed the previous or current GAHT regimen was also ascertained. Additionally, the history of and desire for a specific type of GASP were extracted. More information on the variables, that is, standardised questions/scales/criteria used to measure potential responses and the analytical transformation of these data, are summarised in online supplemental table 1.

Statistical analysis

We calculated descriptive statistics for patient characteristics and GAHT intake behaviours, including the prevalence of hormone use outside the reference regimen. Doing complete case analyses, we estimated the associations between hormone use outside the reference regimen and covariates chosen a priori⁹ using generalised linear models with a Poisson distribution, log-link function and a robust variance estimator, which is fitting for analysing common outcomes.^21–23 We included age (18–24 vs 25 and above), gender, employment (yes vs no), location of residence (within Metro Manila vs outside Metro Manila), diagnosis of gender dysphoria (yes vs no), GASP status (no unmet to partially met need vs wanted GASP but has not undergone procedures) and whether the previous or current GAHT was prescribed by a healthcare provider (yes vs no). Since all non-binary individuals assigned male at birth identified as transfeminine, gender was categorised as trans man (TM) or trans woman and transfeminine (TWTFP) for readability. We reported effect size estimates as crude prevalence ratio (cPR) with a 95% CI for bivariable models and adjusted PR (aPR) with a 95% CI for the multivariable model. Moreover, we assessed the effect of unmeasured confounding using sensitivity analysis and expressed the effect using E-values.^{24 25} All data management and analysis were conducted using R Studio (V.1.4.1103, https://posit.co).

Patient and public involvement

Although there were trans people in the research team involved in developing and refining the research question, creating the data extraction forms, interpreting the results and writing the manuscript, the patients and the public were not involved in any processes pertaining to our research’s design, conduct, reporting and dissemination.

Results

From 2017 to 2019, 535 trans patients enrolled in VLY. A total of 282 were excluded: 6 identified as cisgender, 10 were below 18 years old and 266 did not report any history of GAHT use. At baseline consult, 253 (253/535, 47.3%) reported GAHT intake (212 currently and 41 previously). Among those GAHT users (n=253), 107 (42.3%) were TM, 143 (56.5%) were TW and 3 (1.2%) were non-binary people who self-identified as transfeminine. The majority were 25 years old and above (58.5%), were employed (77.8%) and were residing in Metro Manila (72.2%). Almost all were diagnosed with gender dysphoria (94.5%), and only a minority (7.5%) reported that a healthcare provider prescribed their GAHT. Many wanted GASP but had not undergone any procedures (61.7%); only four (1.6%) were post-gonadectomy (table 1).

Table 1.

Study characteristics of trans people who were previously or currently on GAHT, stratified by gender (N=253)

Characteristics	Total (N=253)		Trans men (N=107)		Trans women and transfeminine people* (N=146)
	n	%	n	%	n	%
Age (years)
18–24	105	41.5	41	38.3	64	43.8
25 and above	148	58.5	66	61.7	82	56.2
Employment
Not employed	48	22.2	21	21.0	27	23.3
Employed	168	77.8	79	79.0	89	76.7
Missing	37		7		30
Location of residence
Metro Manila	164	72.2	70	67.3	94	76.4
Outside Metro Manila	63	27.8	34	32.7	29	23.6
Missing	26		3		23
Gender dysphoria
No	11	4.3	6	5.6	5	3.5
Yes	239	94.5	101	94.4	138	96.5
Missing	3		–		3
Unmet need for GASP
No unmet to partially met need	97	38.3	35	32.7	62	42.5
Wanted but has not undergone procedures	156	61.7	72	67.3	84	57.5
Gonads
With gonads	249	98.4	106	99.1	143	97.9
Post-gonadectomy	4	1.6	1	0.9	3	2.1
A healthcare provider prescribed GAHT
Yes	19	7.5	11	10.3	8	5.5
No	234	92.5	96	89.7	138	94.5

*Includes three non-binary individuals who self-identified as transfeminine.

GAHT, gender-affirming hormonal therapy; GASP, gender-affirming surgery/procedure.

Among TWTFP (n=146), 58.9% reported using OCP, all containing ethinyl oestradiol combined with either cyproterone acetate (36.3%) or other progesterone derivatives. Few TWTFP reported the use of different forms of oral oestrogen, taken as oestradiol hemihydrate (12.3%), valerate (11.0%) or conjugated oestrogen (4.1%). Moreover, cyproterone acetate was the most common antiandrogen reported (60.3%), more commonly as a combined oral contraceptive (36.3%) and less commonly as a separate drug (24.0%). Few TWTFP reported other antiandrogens such as various forms of progesterone (44.5%), oral spironolactone (13.0%) and oral finasteride (0.7%). None reported use of GnRH agonist. Among TM (n=107), 79 (73.8%) reported injecting testosterone esters. Less commonly, TM reported intake of various anabolic steroids (18.7%) (table 2).

Table 2.

Hormonal regimens reported by trans people who were previously or currently on GAHT (N=253)

Trans women and transfeminine people*	n=146	%†	Trans men	n=107	%†
Oestradiol			Testosterone
Oral contraceptive	86‡	58.9‡	Testosterone esters	79‡	73.8‡
Ethinyl oestradiol+cyproterone acetate	53	36.3	Testosterone enanthate injection	76	71.0
Ethinyl oestradiol+norethisterone	41	28.1	Testosterone cypionate injection	6	5.6
Ethinyl oestradiol+levonorgestrel	6	4.1	Testosterone cypionate+phenylpropionate +isocaproate+decanoate injection	3	2.8
Ethinyl oestradiol+desogestrel	5	3.4
Ethinyl oestradiol+drospirenone	1	0.7
Ethinyl oestradiol+dienogestrel	1	0.7	Testosterone undecanoate injection	2	1.9
Oestradiol valerate injection	26	17.8	Anabolic steroids	20	18.7
Oestradiol hemihydrate oral	18	12.3	Methandienone oral	13	12.1
Oestradiol valerate oral	16	11.0	Dehydroepiandrosterone oral	5	4.7
Conjugated oestrogen oral	6	4.1	Unspecified anabolic steroid	2	1.9
Oestradiol gel	1	0.7
Antiandrogen
Cyproterone acetate oral	88	60.3
Combined with oral contraceptive	53	36.3
As separate drug	35	24.0
Progesterone	65‡	44.5‡
Combined with oral contraceptive	54	37.0
Medrogestone injection	20	13.0
Hydroxyprogesterone caproate injection	11	7.5
Spironolactone oral	19	13.0
Finasteride oral	1	0.7

*Includes three non-binary individuals who self-identified as transfeminine.

†Percentages do not add up to 100% as trans people took different combinations of multiple drugs.

‡Subcategories do not add up to total, as some trans people took multiple drugs under the same subcategory.

GAHT, gender-affirming hormonal therapy.

Among trans people currently or previously on GAHT (n=253), 151 (59.7%) used hormones outside the reference regimen: 125 (85.6%) among TWTFP (n=146) and 26 (24.7%) among TM (n=107). Among TWTFP taking hormones outside the reference regimen (n=125), 68.8% were taking OCP, commonly taken simultaneously with other forms of oestradiol (22.4%) and 24.0% reported taking non-recommended forms of antiandrogen, most of whom took progesterone and one took finasteride. Among TM taking hormones outside the reference regimen (n=26), 76.9% reported taking oral anabolic steroids alone. A few TM injected non-recommended testosterone esters (11.5%), and a few injected two different formulations of testosterone esters simultaneously (11.5%) (table 3).

Table 3.

GAHT intake behaviours outside the reference GAHT regimen among trans people who were previously or currently on GAHT, stratified by gender (N=151)

	n	%†
Trans women and transfeminine people* taking GAHT outside reference regimen (N=125)
Taking oral contraceptive pills (OCP) containing ethinyl oestradiol	86	68.8
Taking non-recommended forms of anti-androgen	30	24.0
Taking OCP with other oestradiol simultaneously	28	22.4
Not taking antiandrogens despite having testes	16	12.8
Taking antiandrogens alone	7	7.2
Taking oral phytoestrogen	6	4.8
Trans men taking GAHT outside the reference regimen (N=26)
Taking oral anabolic steroids alone	20	76.9
Injecting non-recommended testosterone esters	3	11.5
Injecting two different formulations of testosterone esters simultaneously	3	11.5

*Includes three non-binary individuals who self-identified as transfeminine.

†Percentages do not sum up to 100% as there were multiple characteristics for a patient taking hormones outside the reference regimen.

GHAT, gender-affirming hormonal therapy.

In our bivariate analyses, only gender and GAHT prescription were associated with hormone use outside the reference regimen (table 4). The prevalence of hormone use outside the reference regimen was 3.52 times higher among TWTFP than in TM (cPR 3.52; 95% CI 2.35 to 5.49; p<0.001) and 2.37 times higher among patients taking unprescribed GAHT than in patients taking healthcare provider-prescribed GAHT (cPR 2.37; 95% CI 1.08 to 6.68; p=0.049). In our multivariable analysis, the patient’s gender was associated with hormone use outside the reference regimen. The prevalence of hormone use outside the reference regimen among TWTFP was more than three times higher (aPR 3.22; 95% CI 2.09 to 5.12; p<0.001) compared with TM. To explain away such association, an unmeasured confounder should be associated with both gender and hormone use outside the reference regimen with a minimum PR of 5.89. Furthermore, given the lower bound 95% CI of 2.09, this unmeasured confounder associated with both the variables by a PR of 3.60 could shift the CI to include the null. Hence, the association between gender and hormone use outside the reference regimen was relatively robust to unmeasured confounding.

Table 4.

Crude and adjusted prevalence ratio (PR) with 95% CI for the associations of sociodemographic and clinical factors with the likelihood of hormone use outside the reference regimen among trans people who were currently and previously on GAHT (n=253)

	Reported hormonal use outside the reference GAHT regimen				Crude PR (95% CI)	Adjusted PR (95% CI)	Eest	ECI
	No		Yes
	n	Row %	n	Row %
Overall	102	40.3	151	59.7
Age (years)
18–24	45	42.9	60	57.1	1.00
25 and above	57	38.8	90	61.2	1.07 (0.78 to 1.49)
Employment
Not employed	21	43.8	27	56.3	1.00
Employed	71	42.5	96	57.5	1.02 (0.68 to 1.60)
Location of residence
Metro Manila	65	39.9	98	60.1	1.00
Outside Metro Manila	33	52.4	30	47.6	0.79 (0.52 to 1.18)
Unmet need for GASP
No unmet to partially met need	35	36.1	62	63.9	1.00
Wanted but has not undergone procedures	67	43.2	88	56.8	0.89 (0.64 to 1.23)
Gender dysphoria
No	5	45.5	6	54.5	1.00
Yes	97	40.8	141	59.2	1.09 (0.52 to 2.77)
A healthcare provider prescribed GAHT
Yes	14	73.7	5	26.3	1.00
No	88	37.6	146	62.4	2.37 (1.08 to 6.68)*
Gender
Trans men	81	75.7	26	24.3	1.00	1.00	5.89	3.60
Trans women and transfeminine†	21	14.4	125	85.6	3.52 (2.35 to 5.49)*	3.22 (2.09 to 5.12)*

*Significant at p<0.05.

†Includes three non-binary individuals who self-identified as transfeminine.

GAHT, gender-affirming hormonal therapy; GASP, gender-affirming surgery/procedure.

Discussion

This study is the first in the Philippines to describe GAHT intake regimens and behaviours among TM, TW, and non-binary people seeking gender-affirming care. At baseline consult, almost half reported GAHT intake, of whom the majority were taking unprescribed GAHT. A quarter of TM and most TWTFP reported hormone use outside the reference regimen. Taking unprescribed GAHT and gender were independently associated with a higher prevalence of hormone use outside the reference regimen. However, on adjusting for covariates, only gender remained significant.

The high prevalence of unprescribed GAHT (89.7% among TM and 94.5% among TWTFP) was not surprising in a gender-affirming clinic of LMICs, such as the Philippines. Moreover, since medically supervised GAHT is highly inaccessible this illustrates the self-medicating behaviours that trans people do amid their unmet healthcare needs. Nonetheless, this finding should be taken with caution because of the convenience sampling employed and the infancy of gender-affirming care in the Philippines.

Studies in other LMICs which used non-clinic samples involving broader geographical areas,^{9 26 27} with one employed a more robust sampling technique,²⁶ had similarly high rates of trans people reporting use of unprescribed GAHT, particularly TW. Contrastingly, in HICs, where gender-affirming care may be more accessible,²⁸ lower prevalence of use of unprescribed GAHT among trans people on GAHT in both gender clinic²⁹ and non-clinic samples were observed.^{30 31}

Using WPATH-SOC8 as a reference, 24.3% of TM and 85.6% of TWTFP in this study used GAHT outside the reference regimen. The prevalence is as high among TW but notably lower among TM compared with a national online cross-sectional study in Thailand.⁹ Methodological nuances between the studies may explain these differences. First, the study in Thailand used the 2017 Endocrine Society Guidelines (2017-ESG) as the reference. The only difference in the recommended regimens between the WPATH-SOC8 and the 2017-ESG is the inclusion of oestradiol gel in the former. However, only one participant in the current and the Thailand studies reported oestradiol gel use. Second, unlike our study, which only considered drug and/or administration route as criteria for the alignment with the reference regimen, the Thailand study also considered dosing frequency. Lastly, our study involved a convenience sample of gender-affirming, care-seeking trans people, as opposed to the Thailand study, which involved a non-clinic sample.

Likewise with the Thailand study, OCP use was among the most common reasons for hormone use outside the reference regimen among TWTFP.⁹ OCP use for GAHT is prevalent in Asian countries due to its affordability and accessibility over and under the counter.^{8 9 32} Moreover, like in other studies,^{8 9} OCP was taken simultaneously with other forms of oestradiol. This practice of overdosing has also been noted in previous studies in Metro Manila¹¹ and other countries, commonly with the motivation to accelerate bodily changes.^{5 33} Among TM in our study, using anabolic steroids was the most common reason for deviating from the reference regimen, unlike in the Thailand study,⁹ where it was reported as rare. However, unlike our study, most of TM in the Thailand study already received GAHT prescription. The most common reason for deviation in the reference regimen in the Thailand study among TM was being prescribed GAHT with higher doses in lesser frequent intervals. However, this dosing frequency is determined to be safe and efficacious among Asian populations in Japan.^{9 34} Moreover, in our study and the Thailand study, other forms of testosterone esters not included in their corresponding reference guidelines were reported being used. The European Society of Sexual Medicine position statement is more inclusive in recommending testosterone esters overall,¹³ which would allow other forms and mixture of esters reported being used in study and other Asian countries.^{9 35}

The high prevalence of hormone use outside the reference regimen in our analysis may also be explained by the following. First, it may be explained by the high prevalence of taking unprescribed GAHT which is associated with a high prevalence of hormone use outside the reference regimen. As with studies in other LMICs,^{9 26 33} TW often seek GAHT advice from fellow TW who are experienced with GAHT,⁶ primarily because of the trans-related discrimination they experience in healthcare settings.^{10 11 36} Many trans health services were often provided alongside services targeted at cisgender men who have sex with men (cis-MSM), which has caused them discomfort from being misgendered and experiencing stigma from cis-MSM.¹¹ Experiences of discrimination were reported even among HIV clinic providers trained for gender sensitivity.¹⁰ Unfortunately, less is known among TM and non-binary people in this regard. Second, no hormones are approved for GAHT in the Philippines.¹⁶ Anecdotally and in other studies, trans people get their hormones from unregulated sources, such as unlicensed providers,^{8 26 37} abroad,^{11 16} online,8 11 26 37 38 grey market³⁷ and peers.8 11 26 33 37 Many TW use OCPs despite being not recommended not only because these are ineffective for achieving recommended serum hormonal concentrations but also because these contain ethinyl oestradiol, putting trans people at heightened risk for cardiovascular issues.^{1 39} Unlike the Thailand study,⁹ TWTFP have approximately thrice the prevalence of hormone intake outside the reference regimen compared with TM. This finding may be explained by the high diversity of oral feminising hormones, including those not recommended, compared with masculinising hormones which are primarily injectables.⁹ Oral forms of hormones may reinforce TW to do trial-and-error with their GAHT regimen^{11 38} and may allow them to start at an earlier age compared with TM.⁹ TW were also reported experimenting to search which hormones are hiyang, or compatible with, for them.¹¹ Hiyang is a Filipino folk concept of perceiving medications as safe and effective,⁴⁰ commonly by self-assessment.

The high prevalence of hormone use outside the reference regimen may also suggest limitations in the global applicability of WPATH-SOC8, which the guidelines acknowledge.¹ WPATH-SOC8 is limited by the disproportionately lesser data from Asian populations. Apart from physiological characteristics, Asian trans people, particularly those from LMIC, are subjected to unique structural barriers to GAHT attributable to the intersection of stigma based on race, class, religion and cultural values.^{8 41} The WPATH should continue considering emerging documentations of trans grassroots community-based practices and values and nuances in the clinical practice in Asia. Unfortunately, only few studies have explored the clinical effectiveness and safety of GAHT regimens, even including those not medically supervised regimens,³² among Asian transpeople.32 34 42 43 Further studies will improve and contribute to the global applicability of WPATH recommendations.

The Philippine health system is unresponsive to the GAHT needs of trans people. In an unsupportive health system, self-care, particularly self-administration, has been suggested as a harm reduction approach to rapidly expand access to quality GAHT to increase the quality of life of trans people.⁴⁴ Self-care is the capability of individuals and communities to do health promotion, disease prevention and health maintenance in the presence or absence of a healthcare worker.⁴⁴ Self-administration of GAHT refers to either self-injecting of prescribed hormone or self-prescribing commonly and previously used oral or topical hormones.⁴⁴ Given our study’s high intake of unprescribed GAHT, self-administration practices among trans people should be further elucidated, particularly among TM. Moreover, the role of the trans community in self-care is undeniably substantial, as many trans people receive their information on GAHT from experienced peers.9 26 33 37 38 Trans community-based mentorship may justify the expansion of trans people-led community-based clinics. The comprehensive, accessible and up-to-date medical information on GAHT with capacity-building training could be provided to transcommunities, increasing their proficiency in GAHT and ensuring patient safety inside and outside the clinic.

The health system should respond to the GAHT needs of trans people. It is ideal that hormones should be approved for GAHT use. However, this non-approval has been attributed to the lack of robust clinical research on the safety and efficacy of hormones for gender affirmation.⁴⁵ Studies on these should be prioritised, and at the same time, drug regulatory agencies may consider drawing recommendations from the available copious evidence on the efficacy and safety of GAHT regimens. Moreover, trans inclusivity among providers and facilities should be ensured through cultural changes and adding SOGIESC in the healthcare worker curricula. Furthermore, overarching sociocultural underpinning of trans-related stigma should be addressed by policies and laws protecting the rights of trans people.

We acknowledge several limitations in our study. The secondary data analysis nature of the study was limited by missing and uncollected data, which precluded the inclusion of other factors that could be associated with our outcome (eg, income). Hence, we could not rule out confounding factor bias. Moreover, as dosing frequency may be inaccurately reported, we dropped this as a criterion for our outcome measurement. Future studies should include dosing frequency for the criteria for outcome measures.⁹ Furthermore, the cross-sectional design precludes inferences on causality. We used data from gender-affirming care-seeking trans people who accessed care in Metro Manila; hence, our findings should not be generalised to all trans people in the Philippines. This sample may have substantial desire for GAHT, which may inflate our prevalence estimates. Limitations withstanding, this study is the first to discuss GAHT intake behaviours among TM, TW, and non-binary individuals in the Philippines. This study provides essential information to improve and develop clinical services and health systems responsive to the unmet GAHT needs of trans people.

Conclusion

Our findings may suggest that trans people act on their high unmet needs for GAHT amid an unsupportive health system. Therefore, whereas structural and holistic health system changes are warranted, community-based self-administration practices in GAHT among trans people should be further explored and empowered.

Data availability statement

No data are available. Data analysed are not available due to the risk of identifying individual patients.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

The ethics approval of this study was granted by the University of the Philippines-Manila Research Ethics Board (UPMREB Code: 2021-105-01) before the study started. The study followed the principles of the Declaration of Helsinki (2013), along with the Guidelines of the International Conference on Harmonisation-Good Clinical Practice (ICH-GCP), E6 (R2), other ICH-GCP 6 (as amended); National Ethical Guidelines for Health and Health-Related Research (NEGHHRR) of 2017 and the Philippine Data Privacy Act of 2012. Written informed consent from the participants was not required in our study and the need for informed consent was waived by the UPMREB.