Introduction

LGBTQ + individuals in the Philippines continually experience numerous instances of discrimination and inequality since the country does not always support their rights and lacks anti-discrimination bills (Robillos et al., 2015). In contrast, several countries, such as the United States of America, Taiwan, and Canada, implemented bills that gave the LGBTQ + community equal rights to those of the prevalent social groups that conform to norms, notably by legalizing same-sex marriage (HRC, 2022).

A study by De Leon and Jintalan 2018 showed that Filipinos seem to tolerate gay individuals within the media. However, the outcomes tend to be different if they are put into a broader perspective. Their study found that Filipinos only tolerate same-sex attraction and do not accept it in society due to the influence of social constructs brought by the Catholic religion and colonial and post-colonial periods with the Spaniards; particularly, Filipinos lose acceptance of same-sex marriage and their legal union.

The term “LGBTQ+” is an initialism that is used to describe the identities of individuals who do not identify as straight or cisgender; it stands for lesbian, gay, bisexual, transgender, and queer, with the plus representing other identities that do not fall within gender binary or heterosexual identities (Cooper et al., 2020). Within this community, transgender refers to people whose gender identity, gender expression, or behavior differs from what is generally associated with their assigned sex at birth (APA, 2014).

The transgender community continually suffers from poor quality of life as they navigate multiple systems of oppression despite the success of the transgender movement over the last decade, which has resulted in increased public awareness and substantial legislative triumphs (Fredriksen-Goldsen et al., 2019; James et al., 2016; Sreyoshi & Vismita, 2018]. Quality of life (QOL) refers to a broad, multidimensional concept that usually includes subjective evaluations of both positive and negative aspects of life (CDC, 2018). QOL combines social, economic, and environmental indicators that must be sustained and fostered positively to ensure optimal human living (Michalos, 2013]. Moreover, a comprehensive study conducted by Gupta and colleagues 2018 highlighted a clear association between the socio-demographic characteristics of transgender individuals and their overall quality of life.

According to Jellestad and colleagues (2018), gender incongruence is one factor that negatively impacts an individual’s quality of life. In the United Nations report, it has been said that the transgender community has suffered discrimination and inaccessibility to information that prevents them from living healthy and stable lifestyles (UNDP & USAID, 2014). Reaching various elements of the transgender experience, such as understanding and expressing one’s identity, is critical for overall health, welfare, and gender affirmation for transgender people (Restar et al., 2021). Today, trans people encounter minority stressors such as structural violence (i.e., discrimination, abuse, and stigma), which obstruct their progress toward these goals. In addition, transgender people experience challenges at work because people typically reflexively and unconsciously label others by gender (Sawyer et al., 2016). Given the fear of prejudice due to inherent discrimination, achieving authenticity at work is difficult for the transgender community (Priola et al., 2013; Davidson, 2016).

Velez and colleagues 2016 also found that low levels of transgender congruence can make transgender people feel “dehumanized.“ This experience results in a pattern of behavior that makes them compulsively exercise to improve body satisfaction. The increase in body satisfaction would translate to much higher levels of transgender congruence. Transgender congruence is the degree to which transgender individuals feel genuine, authentic, and comfortable within their external appearance and presence and accept their real identity rather than the socially prescribed identity (Kozee et al., 2012]. A sense of congruence is essential to the functioning and mental well-being of transgender and gender nonconforming (TGNC) people, particularly body satisfaction, sexual satisfaction, and self-esteem (Austin & Goodman, 2016; Jones et al., 2019; Martin, 2020]. This statement is further supported by Owen-Smith and colleagues’ (2018) findings, wherein the post-stages of gender-confirming treatments exhibit a decline in distress levels for patients who underwent them. Additionally, a study by Van Den Brink and colleagues 2020 discovered that high levels of transgender congruence result in higher self-esteem, mainly when there is infrequent rumination about one’s perceived gender identity. Furthermore, the authors’ data claim that transgender congruence projects negative or positive results in resonance with its levels.

According to Carl Rogers 1959, an individual develops a tendency to self-actualize; specifically, an actualizing individual is described as fully functioning. However, the basis of self-actualization is the congruence between an individual’s self-image and their ideal self. Rogers believed that self-esteem was dependent on how a person evaluated themselves. This self-evaluation is crucial in assessing an individual’s self-worth. High self-regard indicates healthy self-esteem, while negative self-assessment suggests a lower level of self-esteem. These evaluations incorporate our comparisons to others and others’ responses, which affect how an individual views themselves and how they ideally view themselves. The discrepancy between one’s self-image and ideal self can negatively impact one’s health, thus preventing self-actualization. Despite the various studies performed to learn about the impact of gender congruence on quality of life, its influence on transgender people remains insufficiently explored. For instance, Rogers’ (1959) theory of personality solely focuses on the congruence of every person’s QOL rather than a specific group of people, notably the congruence and quality of life of transgender people. With this, a study by Jellestad and colleagues (2018) revealed that nonbinary individuals are more likely to be confronted with stigmatization experiences that result in a negative impact on their mental health, thus affecting their quality of life. To specify, nonbinary individuals identify themselves as neither male nor female, have a gender other than male or female, have multiple genders, or do not have a gender at all (Liszewski et al., 2018]. Therefore, predicting the influence of transgender congruence on the quality of life of transgender individuals is beneficial in a conservative country like the Philippines.

Trans Pinoys and Trans Pinays are terms used in identifying Filipino transgender men and women (David, 2021). The quality of life of Trans Pinoys and Trans Pinays has improved in contrast to previous iterations of Philippine society. Research by Flores (2019) has indicated a steady increase in social acceptance in the Philippines from 1981 to 2017. These iterations involve concealing their identity and dealing with prejudice, criminalization, systematic violence, a lack of legal recognition, and restricted freedom of expression (Manalastas et al., 2017). However, judgment, discrimination, and prejudice are far from being eliminated in collective thought, usually manifesting through disapprobation and poised to continually dilute social relations for years to come (Montaño et al., 2022). These issues become challenging for the transgender community, which has been systematically denied opportunities due to prejudice and societal scorn, a phenomenon many Filipinos believe is still present today (Manalastas & Torre, 2012).

We believe that the perspectives and experiences of Trans Pinoys and Trans Pinays can make remarkable contributions to existing literature. Transgender research in the local Philippine context can benefit the improvement of transgender rights movements in the country, mainly by promoting their legal status and lessening or eliminating discrimination against the said minority. Additionally, exploring the significance of transgender congruence on the quality of life of transgender individuals may aid in identifying the factors that affect these two, contributing to the lack of research on the transgender community.

Thus, this study hypothesizes that a significant link exists between transgender congruence and quality of life among trans people and that higher trans congruence predicts better quality of life among trans people. Additionally, examining the congruence and standard of living that Trans Pinoys and Pinays in the Philippines experience can help us better comprehend their distinctive lived experiences within our cultural and societal context.

Method

Design

The current study used a mixed-methods sequential explanatory design to investigate transgender congruence and the quality of life of transgender individuals. Bernard 2014 claims that using a mixed approach has resulted in a surge of collaborative and creative research across disciplines. By integrating quantitative and qualitative data analysis in a single study, patterns of change can be revealed over time and help show individual and contextual factors influencing the observed patterns (Taguchi, 2018]. The goal of the study’s Phase I is to determine the predictive relationship between the transgender congruence and quality of life of Trans Pinoys and Pinays. Sequentially, Phase II’s goal is for the qualitative data to be able to investigate and explain the quantitative results of Phase I in further detail.

Phase I was a cross-sectional, predictive research design by Johnson 2001 that primarily uses data collected at one point to forecast a criterion variable of interest, such as quality of life, by analyzing the relationship with a predictor variable, such as transgender congruence. In a cross-sectional study, the investigator measures the outcome and the exposures of the study participants at the same time (Setia, 2016]. Phase II was a phenomenological research design that sought to understand and describe individuals’ first-hand experiences and perspectives regarding a particular phenomenon or lived experience. By employing a qualitative approach, a study focuses on an individual’s lived experiences within the world (Neubauer, 2019). Thus, we aimed to explore the meanings and essences of congruence and quality of life experiences as they are perceived and interpreted by our transgender participants.

Participants

A total of 125 Trans Pinoys (n = 56) and Trans Pinays (n = 69) aged 18 to 64 years old (M = 26; SD = 7.22) were recruited from various social media platforms (e.g., Facebook, Instagram, Twitter), LGBT organizations (e.g., Psychological Association of the Philippines’ LGBT Psychology Special Interest Group, Transmasculine Philippines, Pride PH), and referrals from participants themselves.

We executed a snowball sampling technique in our data collection for Phase I since this method effectively reaches small or stigmatized groups (Kirchherr & Charles, 2018). Certain limitations are also acknowledged since we could not significantly represent the whole population of transgender people in the Philippines in our sample. We also delimited the selection to include only trans-Filipinos who resided and lived in the Philippines during data collection to control for other cultural influences. For Phase II, we randomly chose 10 participants from the Phase I sample who expressed interest in being interviewed. All the participants in our study consented to answering the online survey and being interviewed voluntarily without remuneration.

Measures

Transgender Congruence Scale (TCS)

The TCS is a 12-item self-report questionnaire developed to measure the degree to which transgender individuals feel genuine, authentic, and comfortable with their gender identity and external appearance (Kozee et al., 2012). The scale scored highly in terms of reliability, with a 0.92 Cronbach’s alpha, thus confirming its internal consistency. Initially, the TCS was expected to positively correlate with the presence of meaning in life and life satisfaction and negatively correlate with anxiety, depression, and body dissatisfaction. These hypotheses were eventually supported, proving construct validity. Two subscales emerged during the construction of the scale. Appearance Congruence subscale refers to the perception of transgender individuals that their external appearance represents their gender identity (e.g., I am generally comfortable with how others perceive my gender identity when they look at me). The Gender Identity Acceptance subscale indicated the extent to which transgender individuals accept and take pride in their gender identity (e.g., I am not proud of my gender identity). The items of the TCS are completed using a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The average of all 12 items must be calculated and recorded to determine the test taker’s total score; responses to items 6, 8, and 10 are reversed before scoring. The higher the score, the greater the transgender congruence of the individual. The TCS’s internal consistency using Cronbach’s coefficient alpha in the present study is 0.889.

Quality of Life Scale (QOLS)

Conceptualized by Flanagan in 1970, the QOLS was originally a 15-item instrument that measured five conceptual domains of quality of life: material and physical well-being, relationships with other people, social, community, and civic activities, personal development and fulfillment, and recreation. Burckhardt and Anderson 2003 retrofitted the instrument to include people with chronic illnesses. Currently, the QOLS contains 16 items (e.g., Material comforts, home, food, conveniences, financial security, and work) and is answered using a Likert scale format ranging from 7 (delighted) to 1 (terrible). The reliability of this scale lies between Cronbach’s alpha of 0.82 and 0.92, proving its internal consistency. Separately, the content validity of this scale is verified by the quality and quantity of descriptive research done based on the scale. Convergent and discriminant validity were evidenced by high correlations on the total scores in the quality of life scale (QOLS) to the Life Satisfaction Index-Z (LSI-Z) and low to moderate correlations to the Duke-UNC Health Profile (DUHP) physical health status subscale (r = 0.25 to 0.48) and a disease impact measure, the Arthritis Impact Measurement Scales (AIMS) (r = 0.28 to 0.44) (Burckhardt & Anderson, 2003]. All answers from the 16-item inventory are summed to determine the total score of the QOLS; the higher the sum, the greater the individual’s quality of life. The QOLS has a Cronbach’s alpha of 0.904 in the current study.

Interview Guide

We developed an interview guide, or aide memoir, to steer the interview towards fulfilling our purpose of validating the quantitative data collected from the first phase of the research. The aide memoir was guided by the central question: What are your lived experiences as a transgender person? This guide facilitated efficient and precise data transmission from the comfort of the interviewees’ perspective gained from their life experiences of transgender congruence and its association with their quality of life. A distress protocol was in place as part of the interview guide to address possible discomfort during the interview process.

Procedure

The two-phased data collection began after ethics approval was secured from the Philippine Social Science Council-Social Science Ethics Review Board (PSSC-SSERB) with Reference Code: CA-22-44. The quantitative first phase of data collection began by enlisting participants from various social media platforms and LGBT organizations in the Philippines; participant referrals also aided in the data collection process. The online survey was conducted through Google Forms, which included the following: a brief description of the study, informed consent and demographic data forms, the test battery (TCS and QOL), and an invitation for an interview. The online survey took 15 to 20 min to complete. The sequence of the TCS and QOL in the test battery was programmed in random order using allocate.monster to control for systematic order effects in answering the scales. The virtual interviews were scheduled with the participants; each recorded interview lasted 15 min to an hour. All participants were granted permission for the interview to be recorded. Interview sessions started with establishing rapport and securing informed consent for a recorded interview, after which the interview started as facilitated by the prepared interview guide. All virtual interviews ended with a debriefing with a distress protocol at hand to address the participants’ concerns. Moreover, social media accounts were used so the researchers’ contacts would not identify the recruited participants. Data analyses followed the completion of every phase of the study.

Results

The quantitative phase results of the study revealed no significant relationship (p-value = 0.076) between transgender congruence (M = 41; SD = 5.99) and quality of life (M = 84.48; SD = 12.69) among our trans participants. The phase two qualitative findings sequentially explained this non-relationship between transgender congruence and quality of life.

Using Braun and Clarke’s thematic analysis, we generated four significant themes that illuminate the quality of life of the trans participants other than congruence, namely: (1) Social Support; (2) Realizing Gender Identity, Authenticity, and Self-Perception; and (3) Challenges to Transitioning.

Social Support

The first theme elucidates the desire of trans-Pinoys and Pinays to receive acknowledgment and affirmation within their macro and micro relationships. This theme serves as a means to assess their psychological and physical safety within the domains they traverse in reality concerning their quality of life. Transgender people are more drawn to social circles, institutions, public figures, organizations, establishments, and advocates who believe they are real men or women. Family, friends, and daily interactions with random people significantly influence how transgender individuals perceive themselves. The more people think they’re a real man or woman (depending on context), the more secure they feel in their outward projections. The more people misgender, discriminate against, maltreat, and reject transgender individuals, the more their psychological well-being is warped and harmed. The participants expressed dismay and joy in their various social experiences in the interview. With that explained, social aspects in the context of the lived experiences of transgender individuals in the Philippines carry broad ideas and facets that compose the society they are immersed in. Most responses mention family, acceptance, and treatment, resulting in the following subthemes:

(1) Family Support

In this subtheme, the influence of the acknowledgment and restraint of the family members of transgender individuals is highlighted, particularly the participants’ parents. It was observed through the participants’ statements that self-expression and gender expression could flourish or be inhibited depending on how the family reacts to transgender individuals. When family members offer support and embrace their gender identity, it leads to a sense of self-assurance and ease in expressing themselves. This encouraging environment may potentially improve their mental health and overall quality of life. Conversely, it can have the opposite effect if family members are dismissive or rejective of their gender identity. They may feel compelled to conceal their true identity, resulting in emotional detachment, anxiety, and negative effects on their mental health. The emotional repercussions of such experiences can be particularly pronounced when authoritarian parents force religious beliefs or customs that undermine the gender identity of the transgender individual. Poor interactions at home and in the family unit may diminish the mental health of transgender individuals and, ultimately, their quality of life. As stated:

“I mean–ayoko rin i-open sa kanila… kasi ano sila… saradong kandadong Born Again Christian. So… grabe… babatuhan lang ako ng mga bible verses nun and shit… so para hindi na lang ako mai-stress, hinahayaan ko na lang sila.”(I don’t want to discuss any topics related to my SOGIE to my family because they’re adamantly Christian, and they would only refute my feelings with bible verses. I just let them be to avoid stress.) (P7-TM).

“My family did not support me at first.“(P10-TM)

“Siyempre pumunta din ako sa point na hindi ko ma-express kasi feel ko ‘yung family ko hindi accepted kasi nga when buying clothes, girly pa rin ‘yung clothes pero gusto ko talaga more on boyish and ang hirap talaga kasi gusto ko mens clothes and mens shoes, mens everything… pero like mga way before… pero dati parang mostly, gano’n itsura pero sa women’s section ko bibilihin.” (There was a point in time where I could not freely express myself because I know my family doesn’t accept me. When I buy clothes, they tend to hinder my decisions. I usually wish to buy men’s clothes, but I just go to the women’s section to conform to my parent’s rules.) (P9-TM).

(2) Social Acceptance

This sub-theme focuses on people’s perspectives regarding being transgender as they share a similar space with a transgender individual. When people refuse to accept a transgender individual’s gender identity, it causes distress and affects the self-esteem of the transgender person. Having to forcibly conform to gender norms that do not align with a transgender individual’s gender identity also causes dismay and disappointment and leaves a lasting impression of segmented freedom. As quoted:

“Mahirap kasi iniisip ko hindi naman ako eto pero ito ‘yung ginagawa ko kasi ito ‘yung accepted ng society.” (It’s difficult staying true to myself because everything I do is in conformity to our society.) (P9-TM).

“Gano’n pero syempre para maging passing sa paningin ng tao. Parang lahat gagawin mo–kahit ilegal ‘yan, gagawin mo…gano’n.” (To be perceived as passing, I’m willing to do everything even if it’s illegal.) (P7-TM).

“The perception of the people in the Philippines for transgender people is negative, and it’s an external factor that affects me.“(P4-TM).

(3) Social Treatment

This subtheme talks about the micro-interactions transgender individuals have with people as they navigate their daily lives. The proper usage of pronouns boosts the self-esteem of transgender individuals. At the same time, misgendering offends them, especially once their physical appearance starts to manifest per their actual gender identity. Teasing, insults, and microaggressions are often detrimental to transgender individuals, regardless of whether they have transitioned. Respect is a fundamental faculty of human interaction, and the lack thereof for transgender individuals is lamented by participants, as showcased by their responses. As stated:

“The kids are sometimes acting as if they know that you are gay, so they are picking [on] you.“(P5-TW).

“Since I started transitioning, I changed everything in my body, so the respect is already there.“(P5-TW).

“Na-mimisgender ako doon kasi kahit balbas sarado na ako doon ah.” (I still get misgendered even if I’m a transman with thick facial hair.) (P7-TM).

Realizing Gender Identity

This theme centers on the process transgender individuals undertake to form an identity that encapsulates their gender identity. In this exploration and discovery stage, transgender individuals realize what gender values most align with their nature, allowing them to construct an identity that they can happily partake in actively. This formation involves a change in perception amongst themselves, a recognition of how they wish to be addressed, and their personal satisfaction regarding their gender identity. Most responses were homogenous to the essence of trying to establish a gender identity that would align with their life expectations as they continued to exist. Establishing gender identity was then chosen as a subtheme.

Establishing Gender Identity

Transitioning is highlighted in this subtheme as it is treated as the measure of progress for transgender individuals in establishing their gender identities. The farther transgender individuals are transitioning, the more secure they are in their development. Changes in physical traits and the tone of voice are two of the more apparent markers for transgender individuals to assess the progression of their transition. The transition’s progress is the marker for determining how well they have established their gender identities. As stated:

“Transitioning has just stopped all of that type of anxiety specifically”(P10-TM)

”I would say that based on the experiences I have that it really matters; transitioning does matter“(P2-TW).

“Siguro ano simula nung nalaman ko kung ano talaga identity ko kasi before na hindi pa ako nag ta transition siguro ano that was way back four years ago sobrang matindi talaga yung struggle ko non kasi syempre di talaga ako passing. Uhh sa boses ko, sa physical appearance–as in wala.” (When I came into terms with my gender identity I wasn’t able to transition immediately. It was an intense struggle for me, because people did not consider me as passing. My voice and my physical appearance—none of it was manly in any way.) (P7-TM).

Authenticity and Self-Perception

The third theme concentrates on the ability of transgender individuals to accept and feel secure in their gender identity and external appearance. This theme highlights their desires concerning their gender expectations and physical reality. Confidence and self-expression are markedly prevalent for transgender individuals who have successfully finished forging their gender identity and are casual with their physical appearance and presentation. Those dissatisfied with their expression and body image exhibit depressive and body dysmorphic tendencies. Additionally, having to move and reveal themselves in ways that do not align with the prescribed norms of their gender identity distresses them. Since this theme is mainly built upon how transgender individuals express their gender identity, gender expression has been identified as a subtheme.

Gender Expression

In this sub-theme, transgender individuals speak about their ability to express themselves according to their gender identity. This sub-theme includes physical appearance and self-expression as facets of gender expression. The comfort level within their own physical form and motion in accordance with their actual gender identity may positively or negatively affect their confidence in themselves as they tread several environments with their gender identity as the compass. As quoted:

“Ayoko nung female parts ko gan’yan. Ayoko basta. ‘Yung boses ko… ayan… so ayon, nag-ano [referring to transition] talaga ako kaagad.” (I don’t like my feminine physical traits, this includes my voice. This compelled me to transition immediately.) (P7-TM).

“Siguro mga 3 years on T na ako. Balbas sarado na rin ako noon. Tapos ‘yung physique ko medyo bulky, hehehe. ‘Di na nga pambabae ‘yung physique ko tapos kung paano ako mag damit–kung ano ‘yung gusto ko.” (I’m already 3 years on testosterone, and I was already developing a good volume of facial hair. My physique was also bulky. My visage was no longer feminine and that encouraged me to dress however I want.) (P7-TM).

“For me kasi, if you can’t express yourself, freely mahihirapan ka.“ (For me, if you can’t express yourself freely–you will suffer.) (P9-TM).

Challenges to Transitioning

This last theme sheds light on the struggle of transgender individuals to attain their fundamental right to health. It touches on whether it is safe, healthy, and affordable to undergo medical transition in the Philippines. Most of the responses complain about the exorbitant costs of hormonal medication and the overreliance of transgender individuals on finding alternatives that are often inaccessible unless someone within the transgender community who is more knowledgeable refers them to backwater brands. Since healthcare is present in most of the responses gathered, it was identified as a subtheme.

Inaccessible Healthcare

Most ubiquitous drugstores in the Philippines often do not stock diverse options for hormone medication. According to the responses, only expensive doses of hormones are sold, which is not affordable to the ordinary transgender citizen with a regular wage. Health insurance companies also consider gender-affirming therapy a cosmetic treatment instead of a mental health one, thus excluding it from coverage. This experience presents a problem because it implies that only those who reside in the upper echelons of the socioeconomic strata have the right to transition. This lack of accessibility may continue to gnaw at the transgender quality of life in the Philippines unless systematic changes to healthcare occur. As quoted:

“I mean, wala–kung bibili ka sa mercury ganyan sa watsons ganyan. As in. sobrang mahal. Yung testo nila parang ano yun ih. Parang shot lang ata per month. I’m not sure. Pero siguro nag ra range siya 10-12k per shot. Ganon. Ganon siya kamahal. Wala akong choice kundi mag hanap talaga ng uhmm… para makapag transition ako in cheapest way. Maraming mga trans brand na nag se sell ng ano–nag se sell ng testo na mura talaga.” (If you’re going to buy [testosterone] at drugstores such as Mercury and Watsons–it’s very expensive. The testosterone available there, I presume, is one shot per month. I’m not sure, but it ranges from 10 to 12k per shot. That’s how expensive it is. I do not have a choice but to find the cheapest way to transition. There are a lot of brands that sell medication that is way cheaper.) (P7-TM).

“Ma-co-compromise naman yung health mo, which is yun nga. Panget talaga dito sa Philppines kasi wala talag–or limited yung access mo. very limited yung access.” (You’re compromising your health. It is not good [transitioning] in the Philippines because you have little to no access. The access is very limited.) (P7-TM).

“Kumontact agad ako kung paano mag transition syempre nung una medyo wala pa akong budget uhhh merong mga trans brand na tumulong sa akin na… na ano. Inindorse nila sakin yung free consultation which is yung ano yun. Victoria by love.” (I contacted [people] about how to transition. Of course, at first, I did not have a budget. There are trans brands that helped me. They endorsed an organization that offers free consultations, which is Victoria by Love.) (P7-TM).

As seen in Fig. 1, a trans-Filipino’s quality of life could be symbolized as synonymous with a puzzle composed of four distinct pieces. These pieces: (1) Social Support; (2) Realizing Gender Identity; (3) Authenticity and Self-Perception; and (4) Challenges to Transitioning are formed based on each participant’s interview responses. These four themes in this puzzle are formed according to each participant’s interview responses. The puzzle illustrates the complex and interconnected nature of the themes and how they contribute to the quality of life among Filipino transgender individuals.

Fig. 1
figure 1

Diagram of the Factors that Affect the Quality of Life among Trans Filipinos

Full size image

Each theme is represented as a puzzle piece, and when put together, they form a complete picture of the experiences of transgender individuals in the community. The puzzle pieces are of different shapes and sizes, representing the different impact each theme has on the quality of life of transgender individuals. The puzzle pieces can be interconnected, with some pieces fitting into others, representing how some themes are more closely related to others and have a greater impact on the quality of life. For instance, the theme of social support may be a larger puzzle piece that connects to the authenticity and self-perception theme, representing how having supportive friends and family can contribute to feeling authentic and positively perceiving oneself. While the realizing gender identity theme may be a puzzle piece that fits into the challenges to transitioning theme, it represents how the struggle to realize one’s gender identity can present significant obstacles to transitioning. The puzzle metaphor helps to visually demonstrate the complex and multifaceted nature of the experiences of Filipino transgender individuals and how the different themes interrelate to impact their quality of life.

Discussion

​​ This study aimed to determine the relationship between transgender congruence and quality of life and whether the former predicts the latter. Quantitative data showed no significant relationship between transgender congruence and quality of life. Our result contrasts the findings of Huit and colleagues (2021), who state a positive relationship between transgender congruence and gender-related well-being, pride, and life satisfaction. And consequently, a negative relationship between transgender congruence and gender dysphoria, internalized transphobia, non-affirmation of gender identity, and gender-related discrimination, rejection, and victimization Likewise, Kozee and colleagues 2012 found that Transgender Congruence Scale scores were positively associated with life satisfaction and presence of life and that higher TCS-10 scores were significantly associated with lower ratings of gender-related dysphoria and non-affirmation. Therefore, body shame and body surveillance negatively affect how comfortable trans women are with their external appearance as a reflection of their gender identity. Moreover, Velez and colleagues 2016 claimed that low levels of transgender congruence make trans individuals feel “dehumanized”; hence, increased body satisfaction would result in substantially higher levels of transgender congruence.

Anderssen and colleagues 2020, however, found that transgender students more frequently reported psychosocial burdens related to life satisfaction, loneliness, mental health issues and disorders, and suicide-related indicators as compared to cisgender students. Furthermore, Bränström and colleagues (2021) showed that transgender people residing in countries with higher levels of structural stigma, fueled by discriminating laws, regulations, and societal attitudes, report lower levels of life satisfaction. Additionally, their study demonstrates that transgender people hiding their identities can account for the majority of this association. Additionally, findings suggest that identity concealment may have a protective effect against the daily discrimination that transgender people face, which further explains the connection between structural stigma and life satisfaction. Transgender individuals who are open about their identity are subjected to more aggressive treatment than transgender people whose identities are more difficult to hide. Their research highlighting the significance of minimizing stigma spans interpersonal, structural, and personal levels. Their findings suggest that altering laws and societal perceptions of transgender people could significantly improve their quality of life. A similar study by Gokilapriya and Annalakshmi 2021 showed that, compared to those in relationships, trans people who were single reported higher levels of life satisfaction. Transgender people who interacted with their biological family and the transgender community reported higher satisfaction levels than those who did not. Although happiness and life satisfaction were adversely connected with income, socio-demographic characteristics also significantly impacted trans people’s good psychological outcomes.

Finally, Motmans and colleagues 2012 revealed a series of univariate analyses showing that transgender people who are older, less educated, unemployed, have lower household incomes, and are single have significantly low quality of life scores. Their findings emphasized that specific social indicators are essential to the health-related quality of life of transgender people in the context of qualitative and adequate medical care. With the studies mentioned above, it is possible that transgender congruence, although personally meaningful, is not the most prominent factor that predicts trans people’s quality of life. This finding is further supported by Reyes and colleagues (2020), who found similar results to the current study, noting that the relationship between transgender congruence and psychological well-being is weak and not significant. Other factors in the quality of life of our participants may be at play other than transgender congruence.

The second phase of the present study revealed that factors other than congruence heavily influence the quality of life. Our qualitative findings pointed out social support, realizing gender identity, authenticity, and self-perception, and challenges to transitioning as significant aspects affecting our trans participant’s quality of life.

The first theme to emerge from the data analysis was Social Support. As the individual interviews were in session, all 10 participants expressed their need for social support in their transition or self-expression. Being accepted and respected by people, especially their family, is the highlight of this theme. Distress was a common denominator for all participants whenever their families asserted religious beliefs or rejected the idea that they identified as transgender. Most participants struggled to form bonds with their families and instead tried to find companionship in other transgender individuals or allies of the LGBTQ + movement. Respect in their daily life interactions has significantly contributed to their self-esteem, as they have expressed joy whenever they are labeled correctly by people as they visit establishments, work, and other institutions. Insensitivity arising from the lack of knowledge, legal protection, and oppressive insights of religion that greatly influence education and politics still plagues the Philippines (Tang & Poudel, 2018). Additionally, the critical insights of Rood and colleagues (2016) state that rejection from family and the general public is a frequent and salient stressor for transgender and gender non-conforming individuals. It further solidified the coherence of the respondent’s claims with each other and other studies catering to transgender individuals.

The second theme generated from the thematic analysis is Realizing Gender Identity. This theme talks about the sequence in which transgender individuals start to morph their gender identity in a way that aligns with their ideal concept of it. This general concept involves being identified correctly by their gender identity, being recognized by people and the government, and being proud of the realization of what they are and what they are not. It was observed among the participants that those who have started transitioning have significantly progressed, and those who opted for surgery exhibited more security and pride in their self-discovery. A study by White Hughto and Reisner (2016) indicates a sharp increase in the quality of life of transgender individuals who have undergone gender-affirming hormone therapy and the reduction of psychological comorbidities such as depression and gender dysmorphia.

Additionally, controlled research by Foster Skewis and colleagues (2021) found that transgender people who have received gender-affirming hormone therapy experience a significant clinical improvement in emotional well-being and social functioning. This research may explain why transitioning is so highly sought-after because it can positively impact the mental health of transgender individuals.

The third theme to emerge was Authenticity and Self-Perception. This theme surfaced, with 8 out of 10 participants stressing the importance of their physical presentation and gender expression. This theme encompasses the way transgender individuals dress, the definition of their physical traits, and their general perception of themselves. Higher amounts of self-esteem and confidence were observed in participants who have grown secure and confident in their gender identity and have established methods by which they can internalize their authenticity. Some participants subtly indicated and expressed that the higher the transgender congruence of a transgender individual, the higher the likelihood they exhibit positive states such as confidence and initiative. A study by van Leerdam and colleagues 2021 agrees with this statement; however, they also focused on gender dysphoria in their research. Their findings asserted that transgender people who have undergone gender-affirming hormone therapy have positively improved their mental health, and gender dysphoric signs or tendencies were mitigated. We can then derive that the more transgender individuals identify with their ideal gender identity, the healthier they will be. This statement justifies the need for the participants to feel satisfied with their bodies and how they express themselves.

The last theme discovered was the Challenges to Transitioning. This theme covers the lack of accessible healthcare and options for transitioning transgender individuals in the Philippines. Two participants expressed that options for administering hormones were commonly limited to injection shots and were far too expensive for a typical person to purchase. Concerns regarding the safety of transitioning in the Philippines were also raised, implying that distrust in healthcare for transgender people in the country has already been cultivated. A study by Abesamis 2022 has given some causes as to why transgender individuals suffer invisibility in healthcare here in the Philippines. The neglect transgender individuals experience in the Philippines is a product of coexisting and interacting prejudicial notions perpetuated by the law, medicine, education, cisgenderism, and the gripping history of Philippine colonization. In addition, a study by Flores and colleagues 2021 purports that healthcare is a significant challenge for the Filipino populace, with about 50% of Filipinos denied access to primary healthcare facilities. This concern is attributed to the maldistribution and scarcity of healthcare facilities in the Philippines.

According to Chanco (2019), the Philippine Wellness Index of 2019 by Philcare has revealed that 40% of the 1350 respondents in the study are not confident in continuing to finance any health-related expenditure. Coincidentally, the Philippine Institute for Developmental Studies (2023) has reported that the Philippine Statistics Authority (PSA) discovered that despite the massive budget allotted by the government for health, Filipino citizens are still compelled to spend on health with out-of-pocket funds.

Conclusion

Transgender individuals experience oppression despite public awareness and legislative triumphs (Fredriksen-Goldsen et al., 2019; James et al., 2016; Sreyoshi & Vismita, 2018). This study aimed to determine the relationship between transgender congruence and quality of life among trans-Filipinos. However, phase 1 results of the study showed no significant relationship between transgender congruence and QOL among Trans Pinoys and Trans Pinays, and transgender congruence did not significantly predict their quality of life. This result is in contrast with studies stating that gender incongruence negatively impacts an individual’s quality of life and that a sense of congruence is essential to the functioning and mental well-being of transgender individuals (Austin & Goodman, 2016; Huit et al., 2021; Jellestad et al., 2018; Jones et al., 2019; Kozee et al., 2012; Martin, 2020; Owen-Smith et al., 2018; Van Den Brink et al., 2020; Velez et al., 2016). The contrast between previous studies’ results and our findings may be attributed to cultural values and norms. The majority of these referential studies were authored by Western researchers, whose work is largely influenced by the individualistic mode of thinking and feeling prevalent in Western cultures. Our study is based in the Philippines, where collectivistic notions are highly valued, imprinting a need and want to be accepted and to belong in one’s own family unit, social circle, and society.

Transgender congruence and a transgender individual’s self-perception would have to take center stage in an individualistic culture where the self is valued and self-actualization in all aspects is the ultimate goal. However, a person belonging to a collectivistic culture would be in opposition to this individualistic notion, since belonging and conforming to societal norms are of high priority for transgender individuals residing in a collectivist culture. Thus, it is important to note that individuals from collectivistic cultures may hold different perspectives regarding transgender individuals. In places like the Philippines, where societal norms and belonging are highly valued, transgender individuals often prioritize conforming to these norms. Therefore, it is crucial to consider the cultural context and understand that the perception of transgender individuals in collectivist cultures can vary significantly from an individualistic perspective.

The trans Filipino participants’ sense of congruence in our study may not necessarily significantly impact their quality of life since social support, realizing gender identity, authenticity, self-perception, and transitioning challenges are more substantial factors affecting trans-Filipinos’ quality of life. As such, transgender people who interact well with their biological family, the trans community, and society have a better quality of life (Gokilapriya & Annalakshmi, 2021; Motmans et al., 2012; Rood et al., 2016; Sawyer et al., 2016). Lack of social support, prejudice, discrimination, criminalization, systematic violence, lack of legal recognition, restriction of freedom of expression, and community belonging in society affect trans individuals’ quality of life (Manalastas et al., 2017; Manalastas & Torre, 2012; Montaño et al., 2022).

Realizing one’s gender identity also affects their security, self-discovery, and mental health; establishing their gender identity positively impacts their quality of life. Moreover, trans Filipinos’ authenticity and self-perception affect their self-esteem and confidence—specifically, how they dress, their physical traits, and their general self-perception (Restar et al., 2021; van Leerdam et al., 2021).

Studies regarding transgender individuals have shown that undergoing gender-affirming hormone therapy and reducing psychological comorbidities improve their emotional well-being (Foster Skewis et al., 2021; White Hughto & Reisner, 2016). Hence, transitioning has a positive impact on their quality of life. Lastly, challenges to transitioning were also found to be a factor, i.e., a lack of accessible healthcare and options for transitioning transgender individuals in the Philippines. Studies regarding healthcare in the Philippines are a challenge to transgender Filipinos because they are not given priority and the facilities for transitioning are maldistributed, expensive, and scarce (Abesamis, 2022; Flores et al., 2021; James et al., 2016; Philippine Institute for Developmental Studies, 2023).

Qualitative analysis of the interviewees’ responses did reveal that trans Pinoys and Pinays do value body image, gender conformity to their true gender identity, and self-actualization, all of which are concepts that relate directly to transgender congruence. However, the interplay of this concept with other themes and subthemes undermines the significance of a single aspect. It is essential for all factors to harmonize with one another, much like the interlocking pieces of a jigsaw puzzle, in order to prevent the obscuring of the transgender self and potential psychological damage.

Limitations and Future Directions

A number of recommendations can be made for future research based on the results of this study. Firstly, to broaden the representation and diversity of the participants, it is recommended to include trans Filipinos who have limited or no access to social media and widen the age range by gathering data beyond social media. It is also essential to note that the study’s self-reported notions were acknowledged as a limitation. Thus, future research should investigate this limitation further by incorporating additional measures and methodologies to validate the self-reported data. Furthermore, it is recommended that future research also explore and examine the lived realities of Filipinos who identify as non-binary, genderqueer, or gender fluid as a means of acknowledging and validating their existence in the Philippines, where they have yet to be fully recognized.

Looking into other behavioral dynamics, issues, and concerns that influence the experiences of trans Pinoys and trans Pinays is likewise recommended. Future research can identify additional barriers and opportunities for intervention that can improve the quality of life of trans-Pinoys and trans-Pinays by examining other behavioral dynamics, issues, and concerns related to their experiences. This endeavor can lead to more effective policies, interventions, and support programs that address the population’s specific challenges and needs. The studies mentioned and the study’s findings, perspectives, and experiences of Trans Pinoys and Trans Pinays can provide remarkable contributions to existing literature.

This study offers a unique opportunity to gain insight into the lives and experiences of transgender individuals in the Philippines. By delving into their lived experiences, we can foster a deeper understanding of the reality faced by Trans Pinoys and Trans Pinays, ultimately leading to greater awareness and comprehension of the trans Filipino community. Research on transgender issues in the specific context of the Philippines holds tremendous potential for advancing transgender rights movements in the country. By promoting legal recognition and combating discrimination against transgender individuals, this research can catalyze significant societal improvements.

Consequently, it would be advantageous for the government to develop strategies aimed at enhancing the well-being and satisfaction of transgender communities. By adopting a conceptual approach towards this objective, policymakers can effectively address the specific needs and challenges faced by transgender individuals, thereby fostering a more inclusive and equitable society.