Hidden Rainbows: Health Needs, Policy Challenges, and Socio-Ecological Factors Affecting the LGBTQIA+ Community in Primary Care in Manila, Philippines

This qualitative study examined lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other minoritized sexual and gender identities (LGBTQIA+) primary care in Manila using a lens of minority stress theory within a social-ecological model. Focus group discussions, key informant interviews, and policy document analysis identified needs, barriers, and policy/institutional determinants. Unmet needs in mental health, sexual and reproductive health, HIV/sexual transmitted infections (STI) care, and gender-affirming care were analyzed. Individually, internalized stigma, anticipated discrimination, misinformation, and financial constraints discouraged disclosure and timely care. Interpersonally, family acceptance facilitated use, whereas rejection and peer-circulated misinformation impeded it. Institutionally, provider bias, limited LGBTQIA+ competency, confidentiality breaches, and recurring stock-outs constrained equitable access. Community organizations and informal networks bridged gaps but faced unstable funding and oversight. At the policy level, weak legal protections, decentralized governance, and financing gaps produced variable access and limited coverage for LGBTQIA+-relevant services. The analysis clarifies cross-level pathways by which policy ambiguity and institutional deficits amplify interpersonal and individual stressors. It specifies practical components of gender-affirming care in primary care-respectful identity practices, privacy-preserving records, and structured counseling/referral for gender-affirming hormone therapy. Recommended actions include mandatory provider training, stronger privacy safeguards, routine sexual orientation, gender identity and expression, and sex characteristics (SOGIESC)-disaggregated data, sustainable contracting with community groups, integrated mental health/HIV/sexual and reproductive health (SRH) with gender-affirming hormone treatment (GAHT) pathways, and financing reforms. Limitations include single-city scope, recruitment through service-linked channels, and a qualitative, cross-sectional design.