Pills, potency and fertility: The illicit trade of male sexual enhancement products in Quiapo, Manila

by Gideon Lasco, MD

In a paradoxical and very graphic juxtaposition of the sacred and the profane, the Minor Basilica of the Black Nazarene in Quiapo, Manila – popularly known as the Quiapo Church – is surrounded by peddlers selling all sorts of products, many of which act as 'pharmaceuticals', in the sense that they are invested with notions of efficacy and potency in effecting cures and enhancing bodies. Given its “medical” function, anthropologist Michael Tan has aptly christened it the “Quiapo Medical Center” (Tan, 2009). He emphasizes the temporal dimension in his lectures about Quiapo, saying that “it changes every time.” (personal correspondence).  

Considering its reputation for selling products that are outside the sanction of the law, the church, and the medical establishment, I decided to focus on enhancers or male potency and fertility, which is one such gray area. I, together with my research assistant Ryan Tuiza, visited Quiapo several times from August to September 2012 to identify which products are sold for male sexual enhancement, to describe how they are sold, and to whom. I was also interested in how the vendors describe their products. 

Ideally, we ought to have embarked on survey of which products are sold for sexual enhancement across genders (heterosexual males and females, homosexual males and females). However, we were limited by our own genders, which, as we found, made it difficult to relate to products that were not deemed appropriate for our use. Moreover, as we observed during our field work, the Quiapo vendors are very suspicious of the people who pass by, even as they offer their merchandise with spiels such as:



Para saan po? (For what?)
Ano ang hanap nyo? (What are you looking for?) 

The first question is interesting because it invites an answer based on the [pampa + x form], which denotes function. e.g. pampaalis ng lagnat (Remover of fever), pampalaki (Enlarger). After the initial visits, we decided to come up with our own opening spiels: 

“Naghahanap po ako ng pampagana sa sex...” (I'm looking for a mood-enhancer for sex..."“May pampa-buntis po ba kayo?” (Do you have something to make someone pregnant?)

These two spiels also reflect the two categories of substances we were looking for, enhancers of potency, and enhancers of fertility. In this short note, I will describe several products that are used for these purposes. Later on, I will continue to reflect more on our Quiapo experiences by offering thematic insights. 

ENHANCERS OF POTENCY

In this category, I use the colloquial usage of the term potency, i.e. male sexual performance. In the context of Quiapo, the attributes of potency – which are also seen as effects of the products – including “harder” and “longer” penile erections, greater physical stamina during sex, and faster “recovery time”. 

1. “Peter Cream” – This white cream from China is said to be a very potent enhancer of sexual performance. The container of the cream is illustrated with Chinese characters, with only “Peter Cream” in Latin letters. We do not know whether the naming of this product has something to do with 'peter' being a slang term for penis in countries like the United States. The effect is described in vivid detail:

Kapag pinahid mo yan, titigas agad yung ari mo. Makakaramdam ka ng kakaibang init... tatagal ka ng tatlong oras, at kahit 5 rounds kayang-kaya. Maaawa ka sa babae. (If you apply it, your penis will become erect. You will feel a strange heat. You will last for three hours, and even 5 rounds is easy. You will pity the woman.)

The peddler is so confident about its efficacy that he even invited us to try it to feel the effect. He adds that he himself uses it, and so does his old uncle. “This is popular with the old men,” he says.

The cream is applied just once, and the effect should be experienced within five minutes. For maximal effect, it is advised that the man takes a shower first before he uses it. 

Peter Cream is sold in different quantities, with ¼ of a container selling for P200, and the whole for P500. 

2. “Five in One” - This tablet is said to combine five different types of desire-enhancers (“pampagana”). Like Peter Cream, it also produces body heat (“nag-iinit ang katawan”) and the effect is seen after five minutes. For maximal effect, the stomach must be full before this is taken. 

Also, testimonials were invoked when the vendors try to sell this product. Depending on the number of tablets, it is sold for PHP 300 -500. 

3. Lana ng ahas (Snake's oil) – This is a panacea that is being offered more openly by the vendors: it is said to cure a myriad of conditions, from “anemic” to rheumatisms. According to one vendor, having it massaged on your body will stimulate heat (i.e. pampainit) which is also a form of sexual stimulation (i.e. pampagana), and is effective for both men and women. 

4. Dugo ng cobra (Cobra's blood) – This is a kind of snake wine allegedly with the blood of cobra on it, and is also said to enhance sexual performance, among other aspects of masculinity (i.e. pampalakas sa trabaho, energy-booster at work). Placed in recycled bottles of Tanduay rhum and other local liquor, you can see the body of the snake inside the bottle, and the liquid is amber-colored. Other bottles have the added ingredient of ginseng, which is also a known Oriental aphrodisiac. It is to be drank an hour before sexual intercourse to have full effect. 

5. Viagra (Sildenafil) – According to at least one vendor, Viagra tablets are also “available”, and interested buyers are asked to wait for 30 minutes. This was picked up by my research assistant, but unfortunately, we were not able to pursue this lead. There is also no way of ascertaining whether the alleged 'Viagra' tablets are authentic. Nevertheless, even with incomplete data, I am including it here for its mere existence is a significant finding.

To recap our rundown of enhancers of Peter Cream and “Five-in-One” seemed to be the most popular options, and are offered by several vendors, but these products are hidden from view, and are covered with manila paper. The herbals, on the other hand, and the oil and wine bottles, are displayed prominently along with amulets, candles, and sachets of leaves. Western medicines, represented in our survey by Viagra, may also be more available than previously thought. 

ENHANCERS OF FERTILITY

In this section, fertility is used in its biological sense, that is, the “natural capability to produce offspring”. We found that there are also products in Quiapo that are being sold for this specific purpose:

1.”Root crops” - This is a liquid concoction sold in bottles, and is said to be made of roots, bark that were mixed with vitamins which serve to “revive the sperm cells”. The vendors say it is made in China. 
It is said to have an effect as soon as one week, and should be taken thrice a day before eating.

According to one vendor, many people have already tried it, and they can attest to its efficacy. He told the story of a couple who failed to conceive after five years of conjugal union. They tried all sorts of cures, but in vain, until the husband started using the root crops. In just two months, the woman got pregnant. 


However, this special liquid formula comes with a steep price: P500 for a small bottle (around 50 mL) and P1000 for a bigger one (100 mL).

2. Vitamix tablet – Other vendors offer “Vitamix Plus” as a cure for infertility. It is to be taken twice or thrice a day before meals, and takes two weeks to a month to take effect. There are no contraindications to its use, and it is sold for P1000-P1500 per blister pack.

Unlike the other products, this one was amenable to further inquiry by searching for “Vitamix” in the Internet. Curiously, although the vendors say it is made in China, the online search identifies its source as an Indian pharmaceutical firm. 

INSIGHTS 

1. The eclecticism of Quiapo – I was honestly expecting to see indigenous and traditional products to come up – the traditional expectation of Quiapo – but a majority of the products we saw were ascribed to China, although we also saw that this does not necessarily mean that the true source is China. Regardless of the origin of these products, however, there are regulatory implications of this trend. More so when 'Viagra' comes up as one of the consumer choices. Three different medical systems are represented in Quiapo: Chinese, Western, and Filipino traditional, and seemingly, all are beyond the reach of regulation.

2. A vast referral system. To follow Prof. Tan's language, “Quiapo Medical Center” is a 'tertiary hospital' with a vast network of specialists, which ironically leads back to the medical profession. The offer of a referral to a doctor, coming from a Quiapo peddler, is demonstrative of the complicity of at least some health professionals. My research assistant also recalls being offered pamparegla in case his girlfriend needs it, hinting at other services: 

May malalapitan tayo ng tulong kung kailangan nyo ng pampalaglag...
(“There are people we can ask for help if you need an abortifacient”)

3. Suspicion and surveillance. Perhaps as an adaptation to the efforts to curb the trade of illicit products, the vendors are visibly suspicious of passersby, and even those who claim to be looking for products. Personally, I felt that I was not able to fully act out the role of a “typical” customer looking for sexual enhancement, or a cure for infertility – hence my strategy of getting a field worker. As if to affirm the existence of the illicit trade, banners surround the Quiapo church warning the public that the trade of abortifacients like Cytotec will be dealt with severely (Postrado, 2009). However, even when these government moves are met with success, there are many other products out there that require regulation and control. 

4. The power of testimonials. To boost their case for their products, vendors usually invoke supposed testimonies of their past customers. The image of an old man, does a lot to boost their case, particularly in the absence of any objective parameter to evaluate the products. Pit against the “evidence-based” medicine of health professionals are the “anecdote-based” medicine of the vendors, which actually appeal more to the public.

CONCLUSION

There exists in “Quiapo Medical Center” a market for products that promise to enhance male potency and fertility. Sold at relatively high prices, these products likewise suggest that there is a substantial the number of people who are willing to buy them, and vendors are quick to offer connections to medical practitioners, suggesting that the "biomedical sector" and the "informal sector" of health care not parallel systems; there are links between them.

With little or no product information, it is not just efficacy, but safety, that is a major concern as far as these products are concerned. Viagra was initially a drug for pulmonary hypertension until  male study volunteers discovered its "desirable" side effect. But this goes to show that these products have systemic effects that can very well be harmful to its users, especially the elderly who are often the target of these drugs. Health authorities should take this matter seriously.  

Made in China, banned in the Philippines, and sold without regulation, these products reinforce the view that “you can buy anything in Quiapo.” If its vendors are to be believed, the price of pleasure ranges from 200 to 500 pesos, “satisfaction guaranteed”. 

Manila

September 2012

REFERENCES

Tan, Michael. “Quiapo Oracle”, opinion article, Philippine Daily Inquirer, January 1, 2009. Available at: http://opinion.inquirer.net/inquireropinion/columns/view/20090109-182286/Quiapo-oracle

Chua, Philip. “Is street Viagra safe?”, opinion article, Cebu Daily News, January 19, 2009. Available: http://globalnation.inquirer.net/cebudailynews/opinion/view/20090119-184254/Is-street-Viagra-safe

Postrado, Leonard. “Quiapo vendors warned anew”, news article, Manila Bulletin, August 15, 2009. Available: http://www.mb.com.ph/articles/216062/quiapo-vendors-warned-anew

Making sense of "Bawal umihi dito" signs in the Philippines

by Gideon Lasco, MD

Bawal umihi dito: It is an ubiquitous injunction in urban spaces, often boldly painted onto walls, and it translates to "it is forbidden to urinate here". The audience? Filipino men, many of whom continue to take the liberty of emptying their bladders in front of walls, electric posts, and yes, jeepney tires. Go to any densely-populated nooks of the metropolis and there's no denying the pungent odor of piss, which ironically juxtaposes with the aforementioned sign, as if to affirm its relevance by its violation.

Occasionally, the sign is accompanied by the threat of fines, i.e. 500 pesos. In some cases, a municipal ordinance is even invoked, complete with penalties such as imprisonment, as if to make sure that the would-be audience will be convinced about the veracity and seriousness of the sign.

But the very existence of these signs call for some thoughts on this matter. What does it mean for our society? How does it bode for our future?

It is a masculine privilege to take a piss in a very convenient way; it is one of the most obvious gender differences a child observes as he or she grows up. The female toddler is laughed at when she pisses, which requires her to assume an inferior, I.e. squatting position. On the other hand, male children find it fun to manipulate their penises, "shooting it in the toilet bowl" when called for, among themselves; there is some experimentation, like as a contest of having the tallest, farthest stream of piss, an early exploration of sexuality. Today, "pataasan ng ihi"  it continues to be a metaphor for male rivalry. Developmentally, it precedes other forms of male contests, such as "palakihan" (having the largest penis). These things suggest that urinating is not seen as an embarrassing activity at all for many Filipino males; it may be labelled as mischievous, but it is not shameful.

It is very likely that for the longest time, nobody bothered to have male urinals, particularly in rural areas where the bare earth is still visible everywhere. After all, it only takes a few hours before the urine, and its smell, is drained by the soil.

But urbanization took place: villagers flocked to cities, and villages became cities. What was once soil was covered with cement; the open spaces became farther and farther away from people's homes. Backyards became smaller, and more people lived in lesser space.

Sanitation became a problem. Where nearby streams freely flowed through villages, carrying, in the cities, pipes and sewer systems were required, and with it, a financial cost, a need to subscribe to water. Comfort rooms, a taken-for-granted feature of modern living, became unreachable to many, especially the homeless, and those living in the slums. Those of us who have always lived with water faucets may likewise take for granted the availability of water, which in many areas have to be collected and transported to their houses. This is the origin of the term 'pila balde' - a queue of pails as they wait their turn for a fill of water. Some of those pails have come several hundred meters away, and having brought it thus far, you will not waste it just to rinse away urine.

I once had the opportunity to ask a slum dweller how she disposes of human waste considering that her houses consisted of a tiny room in a patch of iron sheets and wooden planks. "I just throw it away," she said laughingly, adding, "like a flying saucer".

There are no more open spaces in the city - save for the rivers, the lakes, and the ocean which have become the unfortunate receptacles of human waste and pollution. Of all the structures of the metropolis: the buildings, the subdivisions, the malls, the only one that is truly accessible to the general public is the street, and thus it is in the street where petty crimes happen, where money is earned in ways that skirt the boundaries between legal and illegal, and yes, it is the locus where offences such as urinating occur.

In 2003, the MMDA embarked on a program to populate the metropolis with pink urinals for men. More than a decade later, it is unclear whether this initiative have had an impact, which, given the number of men in the cities, would at best be minimal. In fact, in 2012, an INQUIRER article reports how a government audit found that, aside from millions of pesos wasted on the program, “...the purpose of procuring such urinals was not satisfactorily achieved as manifested by the foul smell coming from most of the urinals installed.” You could almost see the article's title coming: MMDA urinals leave stink in COA report. 

***

"Bawal umihi dito", as the MMDA experience shows, is not simply a numerical deficiency of toilets in our streets. It a sign that we have not fully come to terms with the urbanization of our society.  Not too ago, people lived with the bare earth and rolling streams which cleansed their environments. Alas, the habits of this bygone era persist in the city, which is a concrete jungle, where evaporation takes time and drainage takes forever.

Moreover, it is a symptom of the overcrowding of our cities, a shared adaptation to limited resources, a lack of access to water and sanitation, and the poverty of the environment.

Finally, it is an example of how people flaunt the law, how people know that not all laws are implemented, and how people who are 'madiskarte' can get away with many things in the country. It's not just Bawal umihi dito, but "Bawal tumawid dito" (you cannot cross the road here) and "Bawal magtapon ng basura" (you cannot throw away garbage) and many others that are oftentimes ignored. In this specific form of ordinance, we saw how it is permitted by cultural norms as a privilege of masculinity. I would argue that it is also enabled by a general attitude towards the law that is not helped by government officials being seen as lawbreakers, instead of lawmakers and law-abiding exemplars.

It will take more than municipal or city ordinances to cleanse the streets of putrid smell. It will take a nationwide effort to be disciplined in things large and small, a respect for the law which goes hand in hand with the respectability of the lawmakers and law enforcers, and inclusive growth that will reach the slums, the poorest of the poor. Finally, a civic consciousness should emerge that goes beyond "tapat mo linis mo" towards "tapat natin, linis natin".

Quezon City
January 7, 2015

Circumcision or Mutilation? A critical appraisal of a study that finds PTSD among circumcised Filipino boys

A boy gets circumcised during a surgical mission in Palawan, Philippines (Gideon Lasco, 2014)

A critical appraisal of the study entitled “Ritual and Medical Circumcision among Filipino boys: Evidence of Post-traumatic Stress Disorder” by Samuel Ramos and Gregory Boyle

By Gideon Lasco, MD 

To all Filipino males out there: Would you entertain the thought that as a child, you were “mutilated” and “criminally assaulted” through the procedure of circumcision? An Australian study says just that.

In a paper entitled “Ritual and Medical Circumcision among Filipino boys: Evidence of Post-traumatic Stress Disorder” published in 2000, authors Samuel Ramos and Gregory Boyle studied circumcision among boys aged 11-16 in Batangas, a province in Southern Luzon, Philippines. According to their findings, a majority of the boys had post-traumatic stress disorder after circumcision, and uses the findings to support the general statement that circumcision is a form of physical violence.

How valid is their paper? Can circumcision, which is accepted by over a billion people, be in reality a form of mutilation? This piece is an exercise that critical explores the connection between the “anthropological reality” presented by the authors and the “emic reality” as experienced by myself, who belong to the culture that is the subject of the paper.

This piece uses the qualitative critical appraisal questionnaire by the Critical Skills Appraisal Programme network (http://www.casp-uk.net/).

1 Was there a clear statement of the aims of the research? 
The authors state that they aim to investigate the psychological consequences of “partial penile amputation”. The authors then connect the relevance of this study in building the case that the Filipino practice of male circumcision is “in reality, criminal assault. Evidence of post-traumatic stress disorder (PTSD) would be used as the parameter by which psychological consequence (i.e. harm) would be measured.

2. Is a qualitative methodology appropriate? 
To their credit, the authors employed qualitative methods, which comprise the first half of the paper. Thereafter, an interview is sent out. For such a sensitive, multi-factorial topic such as circumcision, qualitative methods are truly appropriate to make sense of the practice, whether or not in conjunction with a quantitative paper.

3. Was the research design appropriate to address the aims of the research? 
The research design calls for the measurement of post-traumatic stress disorder (PTSD) among children who underwent circumcision; an outcome showing PTSD is then used as a justification in labeling circumcision as “violence”. They used the DSM-IV criteria (a listing of psychiatric conditions) to define PTSD.

There are serious flaws in the research design. In the first place, the very premise of the study is the diagnosis of PTSD according to the DSM-V criteria. How valid is the DSM criteria, especially when doing cultural research? To show how dynamic and arbitrary this criteria is, homosexuality was once part of DSM-II, and today there is growing criticism of DSM particularly with its cross-cultural applicability (Kleinman, 1987; Faraone and others, 2003, Hinton and Fernandez, 2011). Circumcision definitely presents with pain but there is a need for a much deeper analysis before someone becomes qualified to say that it is “violence”.

PTSD is defined in the DSM-V as a condition that "may develop after a person is exposed to one or more traumatic events, such as sexual assault, warfare, serious injury, or threats of imminent death" (APA, 2013), and thus it is highly questionable for circumcision to be included in this category, given that while it presents with "pain", it is a very tolerable kind of pain that is indeed likened as "kagat lang ng langgam" (just like the bite of an ant). In circumcision missions I have attended, it is the boys themselves who volunteer to be circumcised, and there is no sign of emotional trauma on their part after the procedure.Whether or not the boys in questions actually had (or have) PTSD can be subject to further technical questions in many levels.

Finally, the short-time frame given to the study limits its reliability. There are culturally-sanctioned forms of short-term pain and suffering which would find vindication in the future.

4. Were the data collected in a way that addressed the research issue? 
If research issue is “prevalence of PTSD among Filipino boys who undergo circumcision”, the sample is limited and cannot represent the population in question. Moreover, if the research issue is expanded to deal with issues of “harm” and even “criminal assault”, then measurement of PTSD alone gives the researchers with very limited, weak data.

5. Has the relationship between researcher and participants been adequately considered? 
The bias of the researchers on the practice in question is glaring throughout the paper, evidenced by their semantics. For instance, the use of “mutilation” is preferred in this paper, which itself indicates a value-judgment. In effect, the researchers have already stated their preference for the ultimate outcome of their research in question.

6. Have ethical issues been taken into consideration? 
Since the respondents are minors, there are issues of informed consent and confidentiality. Steps undertaken to address these were mentioned in the paper. Ethical approval was also given by their home university in Australia, but I would think that ethical approval from a panel in the Philippines would have been more appropriate.

7. Was the data analysis sufficiently rigorous? Is there a clear statement of findings?
Hasty generalizations abound in the data analysis. For instance, the paper declares: "Despite some methodological limitations, the present study clearly demonstrates the causal role of circumcision in the development of PTSD among Filipino boys." The use of “Filipino boys” is already a misrepresentation, because they were just studying a small section of a province within the Tagalog region.

The next statement is even stronger : “Evidently, there is strong evidence of a causal relationship between circumcision and resultant psychological trauma.” Again, this sweeping claim is not backed with any hard evidence,

The study also does not study the converse of the population, i.e. non-circumcised boys, and whether or not they had any “psychological trauma”. The embeddedness of both circumcised and non-circumcised males within society is ignored, and in this study, only psychological factors are considered, without any attempt to contextualize the definitions to the local culture.

8. How valuable is the research? 
Circumcision is an important practice in the Philippines and many parts of the world, and has been extensively well-documented. However, a research that gives judgments based on a very weak methodology and biased investigators cannot be assigned much value in this growing body of literature on ritual circumcision.

CONCLUSION 
This paper is an example of how “sociological” and “anthropological” studies coming from the outsiders’ (i.e. etic) perspective can be out of touch with the reality they claim to study. Circumcision is as detached from mutilation as an anthropologist is from a judge. Yet, this case underscores the need for us Filipinos to study, understand, and appreciate our own culture. Going back to the circumcision study, the researchers declare: “[Circumcision] is in reality criminal sexual assault.” In reality? Perhaps there is such a thing as an "anthropological reality", portrayed by social scientists and anthropologists, and then imagined (and reimagined) by the rest of the world. If applied on a culture, it can lead to (mis)perceptions that remind us that we have to be a voice in defining our own reality, for if we do not, others will.

REFERENCES
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. pp. 271–280.

Faraone, S. V., Sergeant, J., Gillberg, C., & Biederman, J. (2003). The worldwide prevalence of ADHD: is it an American condition?. World Psychiatry, 2(2), 104.

Hinton, D. E., & Lewis‐Fernández, R. (2011). The cross‐cultural validity of posttraumatic stress disorder: implications for DSM‐5. Depression and anxiety, 28(9), 783-801.

Kleinman, A. (1987). Anthropology and psychiatry. The role of culture in cross-cultural research on illness. The British Journal of Psychiatry, 151(4), 447-454.