The healthcare system in India faces considerable constraints when it comes to providing quality care to citizens. However, a layer of double marginalisation poses major challenges role for queer individuals. Discriminatory behaviour, deliberate misgendering, lack of access to resources and apathy towards the community plagues the system. The tragic death of Ananya Kumari Alex in 2021 highlighted significant issues within the healthcare system, particularly its complacency in providing poor quality care to queer individuals. This negligence often results in people either hesitating to seek medical attention or receiving substandard care.
There is an urgent need for organisations to go through gender affirmative training and be inclusive in meting out services to the queer community. Randhoni Lairikyengbam, assistant director of SAATHII, an organisation that works to increase access to rights, stigma-free and inclusive health support for the queer community, speaks about the challenges and interventions needed.
Are there specific healthcare needs or concerns that are particularly challenging for LGBTQ individuals?
LGBTQIA+ healthcare encompasses a wide variety of issues from mental health to physical health concerns such as HIV/AIDS, substance use disorders, alcohol use, tobacco use, depression, breast and cervical cancer, hepatitis, access to care for transgender persons. Sensitivity, inclusivity and clinically competent care for LGBTQIA+ communities in mainstream health are yet to become a reality. LGBTQIA+ individuals often face a combination of ignorance and discrimination in accessing any type of health care services.
Can you share any specific instances where you saw discrimination by healthcare providers due to a person’s gender identity? Have you ever had to educate a healthcare provider about queer health issues during a medical appointment?
Based on our field experiences around inclusive healthcare services we could see that homophobia and transphobia among healthcare providers is declining to some extent, but is still very much in existence. Even friendly healthcare providers (HCP) have limited or less experiences on the specific health care risk and needs of LGBTQIA+ persons. Many a times due to fear of negative responses or uncomfortable questions from HCP many of the communities do not want to undergo routine health check- ups and end up buying medicines over the counter.
For those empowered and medically knowledgeable communities, a medical appointment can also manifest as an education session but this will be the rarest of the rare. In many of the states that we (SAATHII) work we target to sensitise HCP starting from Frontline Health Workers such as ANMs, ASHAs and AWWs, paramedical staff and medical practitioners in a health facility with a demand placed for inclusive and stigma free health care services and installation of gender neutral washrooms or separate wards.
There have been some successes in terms of getting a gender marker column in OPD tickets, transgender specific OPD area/queue and gender neutral washrooms. Not only this the medical textbooks need to undergo revision in terms of content and factual information about gender and sexual diversity. Having trained and sensitized medical practitioners, and inclusive practices infrastructure such as OPD, washrooms and wards can come a long way in reassuring the communities for proper health seeking behaviour.
What steps do you think healthcare providers could take to ensure respectful and affirming care for transgender patients?
The way forward to ensuring inclusive healthcare in India includes incorporating LGBTQIA+ inclusive content in pre-service and in-service training of doctors, nurses, counsellors, and other health professionals; institutionalising a ‘non-binary’ or transgender option in healthcare facility intake forms, wards and restrooms, and ensuring non-discrimination and anti-harassment policies for LGBTQIA+ staff and students in health facilities and colleges.
Additionally, it is important to sensitise frontline health workers such as ASHAs and ANMs on issues of LGBTQIA+ and gender-nonconforming children, to better equip them to support families of which such children may be a part. The Transgender Persons (Protection of Rights) Act 2019 and Rules 2020 recommends any one state level hospital/ facility to provide specific health care for transgender persons such as counselling, hormone therapy or gender affirming surgery at free of cost or subsidised cost. Most of the states are yet to follow this in principle.
What improvements would you suggest for HIV and STI healthcare services targeted at LGBTQ individuals?
I am not very involved deeply with HIV and STI programs however it is a good practice for communities to be aware about the basic prevention methods, care that can be taken such as Pre Exposure Prophylaxis (PrEP) and Post Exposure Prophylaxis (PEP) and all the treatment methods for STI, along with trained and sensitized caregivers, and availability of these medicines in the government facilities. National AIDS Control Programme should include comprehensive sessions on healthcare needs for LGBTQIA+ communities during training for counsellors and other healthcare providers
Do you think biased perceptions affect the willingness of people to seek healthcare? What would you like healthcare providers to know or understand better about LGBTQ health issues?
Healthcare Providers need to know and understand the nuances around the health issues for LGBTQIA+ persons such as gender dysphoria that trans people face, and minoriy stress that all community members experience.
For instance, a recent study showed that trans men who had undergone sex affirming/reassignment surgery, reported higher self-esteem and lower depression levels, as compared to those who were yet to undergo surgery.
These aspects need to be understood by healthcare providers. Further, healthcare providers should be aware of the tradition barriers to seeking healthcare, such as stigma and discrimination from hospital/clinic staff, and take care to ensure sensitive practices.
Have community support networks and LGBTQ organisations helped in navigating healthcare challenges? Have you encountered health services in India that are LGBTQ-inclusive and supportive, particularly with regards to mental health?
The changes that we have seen so far in the health sector as per my knowledge has been due to direct and indirect contributions from community support networks, leaders and LGBTQIA+ organisations and other non-governmental organisations. The effort and engagement with the public and private healthcare sector should continue to bring about these changes.
The Queer Affirming Counselling Practice (QACP) course developed and rolled out by Mariwala Health Initiative is a good example of community-informed development of training materials and pedagogy, and has led to a wide network of affirming mental health providers across the country.
There are select health facilities in few states of India both private and public that are inclusive of Transgender or LGBTQIA+ mental health care. Such as SCB Medical College, Bhubaneshwar; Rajiv Gandhi Government General Hospital (RGGGH), Chennai; Regional Institute of Medical Sciences (RIMS), and Jawaharlal Nehru Institute of Medical Sciences (JNIMS), Imphal; and few others in Karnataka, Pondicherry, etc.
Randhoni Lairikyengbam (She/Her), an ally and social worker associated with advocacy for LGBTQIA+ inclusive services for 12+ years. The questions have been answered with valuable inputs and review from Dr. L Ramakrishnan
Please note the questions have been answered not based on personal experience but as an ally who works with and for the communities.