 episode of health issues here at TV UP. In health issues, we discuss important matters on health for all ages and all genders. During my medical school days, in the late 1970s, homosexuality was listed as a disease in the DSM, or Diagnostic and Statistical Manual of Mental Disorders. Since then, the classification of gay, lesbian, and bisexual sexual orientations underwent major changes in different editions of Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. DSM-1 classified these orientations under paraffilia, and DSM-2 classified them under sexual orientation disturbance. DSM-3 further modified this and classified them as ego-dystonic homosexuality, before finally dropping the subject from DSM-3-R and subsequent editions. Basically, the American psychiatrists removed this condition from the pathological list of mental disorders. Today, physicians and psychiatrists use the term gender dysphoria to mean the condition of feeling once emotional and psychological identity as male or female to be opposite to once biological sex. As our guest today, we have Dr. Victoria Patricia Trina C. Dalaliana, a clinical associate professor of the College of Medicine of the University of the Philippines, Manila. She graduated cum laude from the University of the Philippines, Diliman College of Social Sciences and Philosophy with a degree in BS Psychology. She specializes in general and adult psychiatry at the Department of Psychiatric and Behavioral Medicine of UPPGH 2011 to 2003 and the Consultation Liaison Psychiatry, Department of Psychiatric and Behavioral Medicine from 2014 to 2015. She is a diplomat of the specialty board of psychiatry in the Philippines in January 2017. Hi Trina. Welcome to Health Issues. Glad to have you here and thank you very much for joining us for this topic. So let's start with the first question. Let's discuss what is gender dysphoria? Okay, so gender dysphoria at its most basic in one sentence. It's actually when your biological sex, your bits are not congruent with how you see yourself with your gender. So our sex is determined by chromosomes. Yes. Women would get X to X chromosomes and the male would have an X and a Y chromosome. And those chromosomes determine our phenotypic features, our outward features, which is defined by society as sex. But gender dysphoria is how your mind, your gender, how our gender is not, how one's gender is not congruent with the biological sex and this causes great distress within the individual where social occupational functioning are no longer going on, are not okay. The patient is in severe distress, cannot do what he or she used to do. Very stressful situation. And what causes gender dysphoria? Well, generally it is actually not as well studied as we'd like, but one of the more common theories I'm sure you've heard of it before in med school. We can go with a biopsychosocial theory. Yes, biopsychosocial theory. Okay, so biologically, basically it's the genetics of it. So there may be a genetic link between having mental illnesses across generations. So you will inherit the chance to get a mental illness, but the actual getting it, the actual genes manifesting into medical into mental illness, suddenly the psychological comes in. So your personality, how you perceive the world and social, how society, how your environment relates to you. So basically it's a mix of genetics and nurture and nature. So the two things actually combine several factors and that determines the gender identity of a specific person. Well, among other things, but yes. And it also determines who gets actual gender dysphoria. I see. So you can be predisposed to gender dysphoria, but you may not manifest it depending on the factors that you describe. Yes, it's never really just one thing. In mental illness, I've noticed it's really easy for everybody to try to point fingers. Was it the mother? Was it the bad professor? Was it society? Was it economics? No way. It's really a role of everything. It's a combination of everything. And it's really a combination. Like people claim that it's because their classmates bullied them because they were more or less effeminate and they were teased and then or they were sexually abused by someone in the town. So all those factors come into this topic of gender dysphoria. So if it comes out of that during a growing phase, can you grow out of gender dysphoria? Is it just a phase in child and development? Potentially. Potentially. Because it's normal to actually question your gender, your sexuality, and sometimes you will explore as a child. So what happens is when you start exploring and you start seeing who you are and then it's really not congruent with what you are biologically, that can cause the distress. When I was a kid, I like to wear the duster of my mother and pretend like I'm a woman or a mommy. Is that a dysphoric problem? Not necessarily. Because it's the playing stuff in the bahay-bahay and the playhouse thing. And if that's what the child saw, what will the child imitate, basically? So exploring is definitely allowed. Being curious and wondering, experimenting is definitely allowed. We cross over into gender dysphoria once this stress happens. So it's entirely possible to have the symptoms resolve. It can go one of two ways. Either you desist, meaning you suddenly ease into your biological sex, that it is also your gender. But there's also a term that persistence. It occurs in around 20% of kids, gender dysphoric kids, that they really do not experience their gender as congruent with their sex. And I had classmates in high school who were in the class in the school acted gay. They were openly gay. But when we go to their house, they're macho. To the father, he's there really macho. So there really is that particular. You can see that the effect in the house is different from the openness and the liberal acceptance in school. Yes, Po. So what's important to remember is that just because let's say you are LGBTQIA, that doesn't necessarily mean that you have gender dysphoria. They're actually different. Okay. So gender dysphoria is different from LGBTQIA. So for the benefit of our viewers, can you define LGBTQIA plus, right? Okay. So L is lesbian. So a woman who is sexually attracted to another woman is another woman. Correct. Gay. A male who is sexually attracted to other males. Another male. L, G, B bisexual. Attracted to both. So you can be male and you're attracted to females and males. And males. Yes. And you can be a female and attracted to females and males. Yes. Okay. So LGBTQ is queer. Queer. What's queer? Okay. Queer. Isn't gay queer? Yes, among other things. Once upon a time, it was used as a pejorative regulatory term. So since then it has been claimed by the community as something to be proud of. Okay. Yes, I am queer. I have a TV show that I watch all the time. The Queer Eye. Yes. Exactly. So basically they've taken it. And empowered it. It became a strength, you know. They have style. They can look at the side. They're gorgeous. And queer became positive instead of negative. Yes. And it can also mean that they do not conform to the gender binary. Okay. Because, right, lesbian, gay, it automatically has implications of a certain gender, right? So it's more collective. Queer is more collective. It can include a lesbian. It can include a gay. Yes. And it can, yes. Anything, it can include those who do not identify with any. Okay. It's a little more general. Okay. Because gender is fluid. Okay. You have to define fluid. So for me, I'm ignorant about gender fluidity is what they call it. Yes. So what is gender fluidity? So by definition fluid is liquid. So padam too big, like water. If you toss it, it can go everywhere. That's pretty much how it goes. Anything goes. That's the local term. That's pretty much, that's pretty much how it goes. That maybe you are lesbian now, but you might be bi-later or you might be cisgender later. Okay. Oh yeah, because that I've seen friends who become male. They were gay in high school and then when you meet them later, they're married, they have a family. Yes. They now cisgender. Yes. So. Oh, we have to define cisgender for our audience. Yes. So cisgender is when your biological sex is congruent with your gender identity, how you see yourself. So it's congruent. It's the same. So I look at myself as male and I act, talk and move like a male. And your bits are male. And my bits are male also. Correct. Okay. So. And then there's the T, the transgender. LGBT. Transgender, that means, that means that, actually, your bits are not congruent with your gender identity, except what's the difference? It sounds the same as gender dysphoria right now. The difference is the level of distress you experience because you can be transgender, but not be distressed. You can still function daily. I saw transgender defined as a surgeon because I'm a surgeon. Are those that undergo transsexual operations? No. No. Before the ideal situation is before they get to, before they are placed on your table. Yes. We diagnose them with gender dysphoria. So Trina, transgender, define that how that's different. There has to be that stress that occurs in the dysphoria, in the difference between the biologic and what is thought of to be their identity. Yes. To the extent that work is interrupted, interpersonal relationships are interrupted, daily function is interrupted. Okay. So that's transgender. Q, I. LGBT. Queer. We dealt with that already. I is intersex. What is intersex? So those with what we call disorders of sex development. So genetic anomalies, androgen insensitivity, basically biologically, there's a medical condition that creates disorders in normal sexual development. So ambiguity. We call it, what do you call it? Those with the different phenotypic, you know, they're born female. They have a chromosome, but they have a genitalia that's ambiguous. So we've defined that before as ambiguous genitalia. But now it's called intersex. Yes. Because they look like either male or female, right? But their genetic makeup is either female or male, but they're looking different. Or same. What's the A? A is asexual. So that means not experiencing sexual attraction or desire. They're not necessarily lower. It's just a way of somebody, how somebody identifies us. Because it's hard to be, it's hard to have everyone else insisting that you are male or female or insisting that you are attracted to male or female. So suddenly they, there's a feeling that they're cut off from the world with no, with no name, with which they can identify. So therefore you have asexual that you don't really feel sexual attraction for others. That's what you're called. Can that be part of what they do in the clergy when they take a vow of chastity? No. Not necessarily. You can be LGBTQ plus or cisgender and still be clergy. And still, I mean asexual. Is asexual the same as chastity? No. No, it's different. It's really no attraction. Yes. The other one is absence of. Absence. Absence from sexual act. What's the plus? Plus, so if you'll notice there's an entire alphabet about it, right? So. I've read more. Yes. Yes. So that's what the plus is for, to make sure that all are included. Inclusive. Yes. What have I been hearing a little more often lately? Pansexual. Pansexual. What is pansexual? So it's basically who, who they're in love with, a sexual preference. Basically, it's not so much a no sexual preference, but a sexual preference for all in the sense that, in the sense that it's not. Pansexual for all. In the sense, in the sense that it's not restricted to LGBTQ, but even those who are in between the spectrums, or another way I've heard it explained was that as long as the person is lovable. Interesting. I can be attracted to that person. Interesting. Okay. So that's pansexual and all the other. So I suppose there will be more variations that came out. Are we supposed to treat gender dysphoria? Do, if I identify it and what, what are we supposed to refer them to the psychiatrists or a psychologist or what, if, if the parent brings a child to you and says, I'm complaining, my child isn't behaving the same way. What are you going to do? Well, at most, at its most basic assess, assess confirm the diagnosis. That's one. And to check the level of distress that is there. So it's more the distress than the orientation. Yes, because the orientation is not a disease. Correct. Actually, now, now you're explaining it very clear to me. Now I understand why they removed it from the SM, because the orientation is not the disease. It's the stress that it delivers to the person because of that orientation. Hmm. So if there is stress, that's what you will treat. Yes. And there is anxiety, there's depression, suicidal thoughts. These are the ones that you will address as a psychiatrist. Very interesting. So you treat the psychiatric. So any person with a gender males or even LGBTQI can have psychiatric problems as well. And that's what is treated. Not the gender dysphoria. No, gender dysphoria is treated. Gender is not treated. Gender is not treated. The dysphoria has to be treated and managed based on what it affects them, right? Yes. So treatment can range from psychotherapy counseling. So purely talk. It can be to help them get comfortable with whatever their gender identity is. So it can be psychotherapy. Yes. Do you use drugs? Depends on how bad the distress is. Not everybody needs meds, basically. Does that proceed to people who would want transsexual operations? The current term for that now is actually gender-affirming treatment. Gender-affirming treatment. Thank you for educating me. So used to be called transsexual surgery. Transsexual surgery, sex change, sexual assignment. Sex change, sexual reassignment surgery. Yes. That used to be the term. And many of them fly to Thailand for that. Yes. Because that's a very popular and apparently cheaper to do in Thailand. And what happens after that? After sex change operation? Well, follow-up is actually not very strong because the tendency is for them to move to an entirely new place where no one knows them. So this is a new area for research. This is a vacuum for research in there because I've heard stories about people who eventually marry and then they get divorced because the husband discovers he was previously male and then there were some kind of deception and they ask for a divorce. So that's the story. So they moved to a place where no one knows them so that the gender assignment. I think our Supreme Court just recently decided that marriage between two sexes is not going to be approved. Yeah, they did that. They did that recently. So will that add additional stress now to couples in the LGBT community? The stress has always been there. That was the government's chance to reduce it. They did not. They did not. So as a psychiatrist you believe that that can be an option to relieve some of the stress? Definitely. Because society now is made for the cis genders. That's a nice statement. Society is made for cis genders. So they're a minority? Yes. Because the majority are cis genders. Can you define cis genders to them? Those with the same, the normal. Yes. Those who have, they're all normal. But those who whose biological sex is congruent with their gender. The same as their gender. Their gender identity is the same as what they write when they say M or F. Yes. By the way, should we add more to the sex? Ideally, yes. Ideally, yes. Because we're all living here. We're all citizens. We're all paying taxes. So I ask you now a question. When does the gender identity develop? If you're born XX or XY, with your genitalia, you will be labeled female or male based on what the pediatrician sees on your genitalia as you come out of your mother. So when does the gender, so that's the sex, right? The sex is either male or female in the birth certificate. So when does this gender identity develop? Early childhood? Childhood? Adolescent? They start age two to four. Already? Yes. That early? Yes. They start manifesting their preferences or what they're interested in. Correct. And then it is further encouraged or discouraged? Depending on the toys I buy for my daughter, for example. And what they're permitted to play with? Or the boys, what they're permitted to play with. Don't play with that. Are you backlocked? Yes. That can happen. Yes. I see. So society really has a way of forming how their gender identity will be based on how society nurtures them. Interesting. And if the society is more tolerant, let's say a girl that wants to play football with the boys or that that can also add to the nurture of the dysphoria. Well, a more open society will actually decrease the chances of people developing gender dysphoria. So what do you think of Philippine society today? Are we accepting of this dysphoria, gender dysphoria, the LGBTQIA community? I'm older than you. So I have seen the generations of stress, acceptance, descent, and then today's community and how people, young people really accept their friends who are with different genders. The stigma is very much alive. It's not very much alive. Even if there's so much acceptance already. Yes. An openness. Because there is definitely acceptance, but it's not entirely there yet. So the good part is that I feel we have a foot in the door now. We're actually discussing it now to be posted online. Interesting. Because now you're, the way you described to me, having been part of the public health system, it seems to be a public health problem as well, because it's the society that puts stress on this gender minority, correct? So if people are not educated, they can add more problem and stresses to this particular group of gender minority. Can I call them gender minority? Is that a correct term to use? Because cisgender would be the gender majority and this LGBTQ would be the gender minority. Oh, interesting. So what happens next? What do you think are your suggestions to accept, to move forward or improve the way society treats them, identify, prevent them from getting stresses, prevent mental illness, depression, anxiety, would do these people in these gender categories? At its most basic, I think education is important, because a lot of what's happening around us sometimes are born from ignorance, not even malice, just ignorance. And it all sounds very complex, LGBTQ, cisgender, transgender. And it actually tests an individual's beliefs as well. So especially people who are raised like me as a Catholic and then the scriptures say something different. And then I have to accept in society gender dysphoria as an educated UP faculty that I have students who are gender preferences. I have to accept them despite my priests or my, you know. In fact, over the time, it has changed, right? You've heard Pope Francis say, who am I to judge them? That's totally different from what's written in the scripture. The one that's coated by Manny Pacquiao. They are worse than animals, right? So, you know, that's the issue here. That's the issue really of education. And I think this episode is really very important in terms of that. I think religion is different, actually, in the sense that it's very important that we don't force our religion on others. Okay, so that's another stressor. Yes, that's another stressor as well. Because it's very easy not to go with a Catholic stance, how it's a sin, it's not allowed, but... And the big religious organizations are dogmatic. Yes. And will take centuries to change. They probably change their belief later on. The thing is, not everyone is Catholic. Correct. Society is not Catholic, necessarily. But it's even worse. I'll talk about Islam. And in one country, they've declared there are no homosexuals in their country. The Imam declared that the president of that country said there are no homosexuals in their country. But when you see the societal pictures, they're obviously gay men and lesbian women moving around that society. Well, we can't answer for them. They're stressed. That's still a level of stress. We can't answer for them. But there, that's pretty much the problem with organized religion, trying to force their beliefs on others who do not necessarily have the same faith. So as a psychiatrist, if a parent brings to you their adolescent child who seem to have gender dysphoria, the one that needs to be treated is the parent. No, not necessarily. Maybe all of them. Maybe all of them. All of them. That's a nice touch. So you'll have some kind of acceptance. Because I remember when I was a kid, there was this joke. The child went home because everybody was bullying him. He was gay. And the father said, okay, let's bring me to your teacher. What are you going to do? I'm going to hit them with my handbag. So that's a nice point. Because then you have to address it as a family and then as a community, right? The whole community in society. Because parents, there's a tendency for them to choose a doctor who will adhere to their beliefs. That's one. So some of them might not make it to the clinic of an ally like me. That's one. Another is... Where you, you be educated. There are medical schools that are pontifical. So how did they conform that? I mean, UP has liberal thinking. We accept these ideas more openly than other universities, which are Catholic universities. So how, how does that play into the issue of gender dysphoria? Well, that depends on how their training goes. Basically, if it is discussed, if it is dealt with. Because I remember my colleague surgeon said, they can't even show pictures of breasts when they discuss breast cancer. Because it's not allowed by the rules of that particular school. Define where it's located or whatever. So that's really how society or the school will, will address them. And that's the one that adds to the stress of the person with a gender dysphoria. Interesting. Any other things you need to talk about? Gender that is important for the public? Well, for one thing, I hope that they know they're not alone. And that there is help. Do you have many patients that are with gender dysphoria? Not really. It's not as common, honestly. So it's not very common, but... So that means they're not really going to the psychiatrist at all because of societal acceptance. We have many successful people who have gender dysphoria in fashion, in arts. We don't really know unless they're distressed. If they're productive, they might not have gender dysphoria. So that's really the key part there. Their stresses involve in their gender identity. So it's not so much being LGBTQ as it is feeling distressed over their gender identity versus their biological sex. So you feel this will be coming along better? Are we progressing as a country, as a society, as a people? I hope so. I think so. We've been taking the good first steps. Manila Med actually has a gender diversity clinic. Gender diversity clinic. That's the first time I've heard of that kind of a clinic. What do you do in a gender diversity clinic? In Manila Med, as I understand, they offer counseling. So psychologists will talk to people with gender dysphoria or psychiatrists. And sometimes it's even just to explore. Wouldn't that be something I'd have to put up in, let's say UP Manila or UP Deliman as a service? Because aren't these issues coming in when they're in college, when the people start to partner with their sexual orientation? Even high school. Even high school, yes. Let's see. The medical city has one. Also. Yes. So there are other many hospitals now with what did you call it again? Gender diversity clinic. That's the name of the clinic they have in Manila Med. In the medical city, if I recall correctly, it's Center for Gender Health. Center for Gender Health. Yes. In terms of putting it up in the UP system, well, that depends, I guess, on the UP system. One way of looking at it is that, one way of looking at it is that, what if in UP, we are already gender sensitive and are dealing with the patients? What if we don't need to create a safe space because the whole university is. Because of the liberal thinking. Yes. Because the whole university is a safe space. With faculty, we have gender dysphoria. We have gender identity and we accept them. We have creatives that have gender identity and we accept them. Yes. And in terms of health care. And they're successful and they're, you know, national scientists or national artists, right. And in terms of health care, we should be able to provide gender sensitive health care to all, regardless, without having to create a clinic for it. That's true. And that brings me to the next question. This issue on the Philippines being an HIV progressive, very high propagation of HIV. And the data shows that it's men having sex with men. And it seems that if I'm a public health person, I have to address this gender minority because that's where the growth is fastest. It's 10 times the regular growth. And if I don't address it, we will have an HIV epidemic. But we are looked at by, when we try to address it, I'm looked at for stigmatizing men having sex with men for addressing that. How do you, how do you expect the public health official to solve something like the spread of HIV in this community, in the LGBTQA community? I think what's important is consultation. Consultation with a community. Because what they need is what they did in Thailand. They offered the use of safe sex being able to make it available, whether you're a sex worker or in the LGBT community and they decrease their propagation of HIV. And pre-exposure prophylaxis. Pre-exposure prophylaxis. Oh, that's interesting. Vaccines. Ish. Ish. They're oral meds, if I recall correctly. Okay. That will present. And not only that, there are people, so that's the first problem. So now I have a whole community of a few thousand that are people living with HIV who are in the LGBT community because of the preference. And how do I deal with them? How do I deal with their public health needs? Again, consultation. See what they need. See their state now. PGH has the sagip unit. Yes. Yes. So they're telling me more about the sagip unit because I see them lined up getting their meds for, that's provided by Phil Health, right? So the access to medicines for HIV is available. It's run by the infectious disease section. Okay. Do some people get referred to psychiatry for support? This year we're starting a program with them. Yes. We're teaming up with them this year. But in the previous years, when we receive referrals from internal medicine for HIV-positive patients, it's usually when they're in patients already, when they're confined. But now we're trying to focus on outpatient as well. So that they can change the behavior practices and be able to prevent the spread of all of this. Very interesting. Outside hospitals, there's also the Victoria Clinic by Love Yourself Foundation. Okay. Love Yourself is one of those that. They're actually doing really great work. So they also do counseling. Oh, that's an important part as well. Counseling and support for the patients. And also, yeah, there is access to the medications and there are also physicians there. That's wonderful. So this is a very interesting topic indeed. Any last words to our viewers out there, whether they're in the LGBT community or whether they're in the cisgender community? So I've learned two words. All right. I think I will teach you a new word. Okay. It is called ally. We can all be allies for the LGBTQ community and even for any minority population we have. This is a call and an opportunity for all of us to help and to serve. Wonderful. So anybody who is having such problems with their sexual orientation, gender identity or expression, I promise you're not alone and I promise there is help. Wonderful. With that, I'd like to summarize and say that gender dysphoria is indeed here in our society and its acceptance is vital in how society addresses these people with gender dysphoria. We are not there to add more stress to them. As we said, we are allies. The medical community and the whole community here at the University of the Philippines actually allies with you and addresses the fact that you shouldn't be hiding and you shouldn't have problems of depression. You shouldn't have problems and that your issues are also our issues. With that, thank you very much. Thank you very much to our guests, Dr. Atrina, and thank you for enlightening me about the issues on gender dysphoria, LGBTQIA community. Goodbye and thank you very much.