In the Philippines, where the visibility of LGBTQ+ is growing, yet health care equity remains elusive, Dr. Antonio C. Sison finds himself working at the complex intersection of psychiatry, gender, and sexual identity.
A psycho-dermatologist by training, Sison has become a trusted point of referral for colleagues—plastic surgeons and general practitioners—who need psychiatric evaluations of patients seeking gender-affirming surgery. Others, usually gay men, are sent to him to manage conditions, such as bipolar disorder, depression, or relationship concerns. In the latter, sexuality itself is not the problem.
“These patients aren’t uncomfortable being gay,” Sison explained. “They come for the same psychiatric issues anyone else would. They just happen to be gay.”
Sison’s approach reflects a broader tension in Philippine medicine. Social acceptance of LGBTQ+ identities has grown in recent years—evidenced by celebrity children coming out and Pride events gaining traction—but clinical protocols remain uneven, especially for transgender individuals.
To address this gap, the Philippine Professional Association for Transgender Health (PPATH) invited Sison to speak in a forum. There, he underscored the mental health dimensions of transgender care, particularly the need to evaluate psychological readiness before surgery or hormone therapy.
“We evaluate for psychiatric conditions that might pose a contraindication,” he said. “For instance, if someone is experiencing major depression, that’s not the right time to undergo surgery.”
But psychiatric clearance, he underscored, should not be seen as a form of gatekeeping. Rather, it ensures that patients are emotionally and mentally prepared for what is often a life-altering transition.
He takes issue with the use of puberty blockers in adolescents
Sison’s views on transgender medical care are shaped by both caution and compassion. While he supports gender-affirming treatments for adults, he takes issue with the use of puberty blockers in adolescents—a practice more common in countries such as the United States.
“In the US, if a young person meets the criteria for being transgender, they can be prescribed puberty blockers,” he explained. These medications suppress sex hormones so the body doesn’t develop the secondary characteristics of their assigned sex at birth.
He recalled a high-profile case where a teenager underwent sex reassignment surgery before entering college. The rationale was to help them to be fully transitioned at the start of college. “That’s the guideline there. I don’t agree with it,” he said.
Sison raised his concerns with a colleague from Harvard, who responded that early intervention could prevent suicide. But Sison countered that if suicidality is the concern, it should be addressed through therapy and psychiatric support, not irreversible medical procedures.
Timing, he believes, is everything. “The prefrontal cortex, which governs decision-making and impulse control, doesn’t fully develop until a person’s mid-20s,” he explained. Making permanent changes to the body before that, he argued, carries serious risks.
He pointed to the growing number of detransitioning cases—individuals who undergo medical transitions and later regret them. “Once you start hormone therapy, brain chemistry begins to change,” he said. “That’s not something we can undo easily.”
‘The prefrontal cortex, which governs decision-making and impulse control, doesn’t fully develop until a person’s mid-20s.’ Making permanent changes to the body before that, he argued, carries serious risks
Still, he cautions against assumptions about what it means to be transgender. Not every transgender individual desires surgery. “There are people who identify as female, wear makeup, and present in a feminine way—but have no desire for top or bottom surgery,” he said. “They’re perfectly comfortable that way.”
This, he said, challenges the idea that surgery is the defining experience of transgender identity. “Gender identity isn’t about anatomy alone. It’s about a person’s internal experience.”
In a separate interview with this writer, Sison elaborated on one of the most misunderstood aspects of transgender health: the difference between sex and gender.
“Sex is determined by chromosomes—typically XY for males and XX for females—but even that has variations,” he explained. “Gender, however, is psychological. This is expressed in a spectrum. Someone with XY chromosome pair might identify his gender as anywhere from ultra-masculine to ultra-feminine. That’s the gender spectrum.”
It is this spectrum of presentation, he notes, that presents challenges in clinical care. If a physician focuses only on a patient’s stated gender and ignores biological markers, critical screenings could be missed.
“For example, a transgender woman—who identifies and presents oneself as female—still has a prostate,” he said. “If a physician fails to take that into account, she may not get appropriate screening procedures. Social affirmation is important, but medical accuracy is crucial for safe, effective care.”
These issues highlight the need for local, evidence-based guidelines for transgender health. Understanding how biology and psychology interact is key to both patient care and medical safety.
That same careful, individualized approach also informs Sison’s broader psychiatric practice. While his transgender patients may need medical evaluations tied to physical transitions, gay clients often come in for entirely different reasons.
“They’re navigating relationship issues or mood disorders,” he said. “But as part of the evaluation, I also need to understand their lifestyle and behaviors—because that influences their mental health risks.”
Among younger gay men, Sison has observed a trend toward open relationships and routine use of PrEP, or pre-exposure prophylaxis
Among younger gay men, Sison has observed a trend toward open relationships and routine use of PrEP, or pre-exposure prophylaxis—a medication taken by HIV-negative individuals to prevent HIV infection.
“In theory, PrEP allows them to engage in higher-risk sexual behavior while protecting against HIV,” he said. “But that’s the keyword—in theory.”
The reality, he warns, is more complicated. “PrEP doesn’t protect against syphilis or other STIs (sexually transmitted infections). And not everyone uses it correctly. There’s often a false sense of security.”
Data from the Department of Health supports this concern. Youth aged 15 to 24 account for 29 percent of reported HIV cases in the Philippines, with 98 percent linked to sexual contact.
Sison also treats patients who participate in chemsex—sexual activity under the influence of drugs like methamphetamine. These gatherings, often organized via coded invitations, are described to him as private parties reserved for physically fit individuals.
“The drugs enhance the experience,” he said. “It becomes ritualistic.”
But the aftermath is frequently emotional. Many of his patients report episodes of dysphoria—feelings of remorse, anxiety, and fear about HIV exposure. “‘Am I still HIV-negative?’ they ask. Then they test, find out they are, feel lucky—and repeat the cycle.”
He avoids moralizing. “Straight people also have multiple partners,” he noted. “This isn’t about condemnation. It’s about understanding behavior so we can guide people toward safer, healthier lives.”
As relationship structures evolve, Sison encourages open communication. When a patient mentions being in an “open relationship,” he always asks what that means—because the terms are rarely universal.
“For some, it means sex only when the partner is present. For others, full independence. Some require disclosure before or after. It’s always a negotiated contract—and those contracts evolve.” What’s open today may be closed tomorrow. Assumptions, he says, are the enemy of good care.
Asked why more LGBTQ+ Filipinos are coming out now, Sison credited a more tolerant social environment. “Society is expanding its definitions,” he said. “It now includes nonbinary and gender-nonconforming individuals. That’s part of the democratic space we’re in.”
But visibility, he cautions, is never permanent. “It can change, depending on political, religious, and cultural forces. Acceptance moves in cycles.”
For now, at least, his patients find something in his care that’s still rare: someone willing to ask questions without judgment, to listen deeply, and to avoid the easy answers.
Clinical training emphasizes diagnosis. But Sison believes one of the most important things a doctor can do is pause—and ask what an experience means to the person living it.
