Worried about getting turned away by doctors because they are under 21, some young Singaporeans have been buying hormonal medication online.
They self-medicate in the hopes of feminising or masculating their bodies so they can soon look like the gender they identify with.
Ms Cassandra Thng, 19, started ordering hormones online in June and took a cocktail of four pills a day. "This is because you need to be 21 and above to get hormones without parental consent. My parents wouldn't consent. But I felt I couldn't wait until I turned 21," she told The Straits Times.
She is not alone. Her friend Jolene Tan, 19, did so for a year.
On discussion website Reddit, a local transgender woman in her 20s told of starting her hormone replacement therapy (HRT) journey at 14.
All said they self-medicated because they heard from friends that they had to be 21 to get prescription hormones from a doctor unless they had parental consent.
The usual route for a person looking to transition is to see a psychiatrist for evaluation. Only when diagnosed with gender dysphoria can the individual be given hormonal therapy, usually by an endocrinologist who will carry out blood tests and recommend dosages tailored for the individual.
Doctors said such self-medication is worrying because of side effects and the questionable authenticity of the products.
Dr Vivien Lim, president of the Endocrine and Metabolic Society Singapore, said: "You've no experience on what to look out for. Advice from friends is just anecdotal."
Psychologist K.C. Lee added: "There isn't one pill for every transman or transwoman."
Potential side effects in the long term include deep vein thrombosis, weight gain, migraines, changes in moods and behaviour and osteoporosis. But the greater concern is authenticity of the pills.
Said Dr Lim: "Who knows what is inside? There could be mercury and you could have issues with major organ damage."
In its response to queries from The Straits Times, the Ministry of Health advised against buying such products off the Internet "as it is difficult to authenticate the safety and quality of products sold online".
"Products sold online could also potentially be counterfeits or adulterated with undeclared potent ingredients," it added.
Doctors also said the emotional and psychological support offered by a psychiatrist are critical for someone who is transitioning.
Dr Lee said: "There can be very awkward stages because transitioning does not happen overnight. Some families are not supportive, so there are risks of anxiety, depression and even around daily functioning: How do you go to work? When you go to the mall, which bathroom do you use?"
Asked if she was confident her online research on dosages was reliable, Ms Thng said: "It was more like desperation, I needed to get something done or it will drive me insane. So long-term health complications aren't really an issue."
As for Ms Tan, she wanted to prevent further masculation of her features.
It is unclear if there is an age requirement to getting HRT. Endocrinologist Abel Soh said there is, but Dr Lim is not aware of such guidelines although she said it was a "grey area". "They are not even allowed to watch R21 films, how am I going to give them hormones to change their bodies?" she said.
The Singapore Medical Council's ethical code says that while it is standard practice for consent for minors to be taken from parents, "you must give consideration to the opinions of minors who are able to understand and decide for themselves".
The Ministry of Health said "young persons who have questions or uncertainty about their sexual orientation or identity should seek professional support".
To discourage self-medication, better services for transgender people and guidelines for doctors are needed, said professionals.
Dr Keng Shian-Ling, assistant professor at the department of psychology at the National University of Singapore, said: "More transgender-affirmative psychological and medical services should be made available to the transgender community so that they will feel more comfortable seeking out professional help."
If there was an age limit, Ms Thng thinks it is important for that to be lowered. "For transwomen who have to do national service, getting hormones earlier is probably something that's quite important."