The qualitative study by Lakshya Arora, Dr PM Bhujang and Professor Muthusamy Sivakami is published in sexual and reproductive health issues.
In-depth interviews were conducted with 15 self-identified LGBTQIA+ individuals who sought healthcare services in six hospitals in the major cities of Delhi and Mumbai and with 23 heterosexual staff at those hospitals. In each city, one hospital participated in both the public, private, and non-profit sectors.
Although the small sample size can be a limitation, the researchers made an effort to enroll study participants from a diverse group of the LGBTQIA+ community. About half were gay and lesbian, and the rest identified as bisexual, asexual, queer, and other types of gender variations. Just under half were not of the same gender.
The hospital staff interviewed worked not only in HIV and mental health services (the focus of most previous studies), but also in departments such as venereology, endocrinology, gynecology, proctology, and surgery.
The LGBTQIA+ community is not homogeneous
The researchers found that most hospital employees (and especially hospital administrators) consider the LGBTQIA+ community to be a homogeneous entity. The unique health care needs of different people are not being met within the wide range of gender diversity and sexual orientation. However, the staff in the HIV departments were less discriminating than others.
Hospital management and health care services are designed and organized on a gender binary basis, which often leads to the exclusion of gender diverse individuals. A transgender woman told researchers:
“In hospital settings, everything is sorted into a binary system — whether it’s an outpatient setting [outpatient department] Lines, medical records, wards, or bathrooms. I was comfortable in feminine spaces, but isolated from everyone.”
LGBTQIA+ participants felt that the lack of appropriate training for healthcare professionals led to discriminatory incidents including humiliation, verbal assaults, and threats to reveal their sexual orientation. A transgender man receiving gender-positive hormone therapy shared:
“When I went to a doctor for a cough and a cold, he was shocked to find out I had a beard and a vagina… He forced me to show my genitals and tried to enroll me in a clinical trial. But I asked him does he treat cough and cold vaginally?”
Another trans man said:
“This guard at the entry gate told me I didn’t look like a normal patient… other patients would be intimidated by my appearance… I should go to an NGO for my healthcare needs instead of visiting this hospital; or I should bring someone from NGO to escort me to the hospital…”
LGBTQIA+ people who came from different socioeconomic classes, castes, religions, and non-urban areas reported intersectional discrimination. Lesbian and bisexual women shared testimonies that reveal discrimination due to both sexual orientation and gender, often exacerbated by other factors.
“We need more open-minded doctors who don’t just make assumptions. I was asked about birth control measures even after revealing my sexuality. Even the doctor made me feel ashamed.”
“she [doctor] She prescribed some medication without any written prescription which turned out to be a high dose of psychiatric medication… Upon questioning, she said she assumed I had family stress (including instances of harassment, abuse, and violence). “
Recent legal reforms have not been implemented in India
India has undertaken important legal and policy reforms in recent years to decriminalize same-sex sexual behavior and promote progress in social welfare for transgender people. But the implementation of the existing laws is very unsatisfactory. The study found that most physicians and hospital administrators were unaware of legal and political protections.
Hospitals lacked policies that are inclusive of all genders and genders. Gender affirmation guidelines in public hospitals have often been limited to establishing sexual harassment commissions and issuing medical certificates to transgender people.
The non-profit hospitals in the study did not have any gender diversity or inclusion policies, except for those against sexual harassment of women in the workplace. Not-for-profit hospitals with religious affiliations have been reluctant to even discuss policies that include LGBT people.
Discrimination against LGBT people was explicit in public hospitals (including reports of sexual harassment) but implicit or subtle in private hospitals. An asexual woman participated in the study:
“Just because I had no feelings, he (the healthcare professional) touched me… and when I wanted to take him to the administration, he said that the administration would not support me, because this is within the framework of the treatment plan to make me sexually active.”
Private hospitals have been reluctant to risk losing the majority of their cisgender clientele if they openly serve the needs of LGBT people.
Some evidence-based services, such as gender confirmation surgeries and hormone therapy, were rarely available. A doctor at a public hospital told the researchers:
Endocrinology as a department is mostly available in tertiary care centers as a super specialty. The endocrinology department in our hospital is mostly limited to thyroid and diabetes, along with private clinics once a week for podiatry, adrenal disorders, pituitary disorders, and growth disorders. We are absolutely thinking of expanding our services to LGBT people (QIA+) as well.”
Another doctor said that no physician known to him is equipped to perform sex reassignment surgery or related treatment.
“Doctors are not trained in such treatment and procedures (sex-positive counseling, hormones and surgical procedures)… India does not have a very skilled medical workforce to perform such procedures.”
The study records the data of several LGBTQIA+ people who have undergone gender reassignment surgeries but are still dealing with medical complications due to substandard care.
The lack of adequate health care for LGBT people and especially transgender people results in people receiving unscientific “care” in the informal sector. Doctor said:
“A weak public health system and a lack of financial independence for LGBT people leads to… [them] Visit the imposters. The treatments offered by the charlatans are ineffective and mostly limited to elixirs, creams and inadequate implants with silicone content.”
Despite the ban on “conversion therapies” by the National Medical Commission of India, the reality on the ground is very different, with study participants recounting harrowing experiences of exposure to such “treatments”.
“The social pressure was so great that they (the family) took me to a religious healer who charges 500,000 rupees. [over US $6000] For hawan (ritual fire) and Rudraksh (bead form)…and when I didn’t turn straight, they spent another 100,000 rupees [$1220] In a conversional psychiatric hospital. “
Not just HIV services but comprehensive health services
“Just like everyone else, people with HIV also face cold, cough, diabetes, chronic obstructive pulmonary disease or may be exposed to other risk factors” that may increase the risk of non-communicable diseases or infectious diseases, Professor Muthusamy Sivakami told Aidsmap.
Colleague Lakshya Arora added, “I spoke to no one Teachers affiliate immigration Who told me that “all these people in the NGOs give us condoms, but they never try to distribute paracetamol”. So, this was a huge change in my way of thinking. While it is undoubtedly important to ensure that HIV services reach everyone, it is equally important to ensure that other healthcare services also reach everyone – especially LGBT people – in a rights-based and non-discriminatory way.”
Sivakami says this qualitative study provides a deeper understanding of the range of discrimination faced by LGBTQIA+ people in public, private and not-for-profit hospitals. The study findings highlight the need for regulatory and systemic changes for non-discriminatory, rights-based access to health care services for LGBT people.
“We need to reform our public health policies so that all LGBT+ people feel comfortable seeking services from a primary or community health care clinic as well as tertiary care hospitals,” said Lakshya. He also affirmed the commitments of Indian public bodies to be gender inclusive. The Section 377 ruling decriminalizing same-sex conduct calls for broader outreach, while the recent Madras High Court ruling banning conversion therapy encompasses the full spectrum of the LGBTQIA+ community and directs the government to promote far-reaching social changes.