Curing Discrimination: Making Healthcare Inclusive for LGBT People
By NADIA GIDEON, THILAGA, & PANG KHEE TEIK.
Many people seem to believe Lesbian, Gay, Bisexual and Transgender (LGBT) people do not face discrimination. Yet, we have received many anecdotal and documented reports by LGBT patients who have experienced discrimination at medical facilities in Malaysia, from doctors who won’t touch them, to being openly shamed by doctors, to receiving hasty, inadequate diagnosis and treatment. Like anyone else, LGBT persons do not want to be discriminated against. Their experiences of discrimination have resulted in a lack of trust towards healthcare institutions. Many LGBT persons even fear that their private information could be used against them. This is why LGBT persons are less likely to seek help, tests, and treatments. They don’t always bother to visit their doctor’s office, or when they do, they find that they are unable to give an accurate and honest description of their health and history. LGBT people who are ill sometimes take longer to get treated, and in some cases, only when it is too late.
It isn’t that LGBT people are more prone to ill health. It is the prejudice and social stigma that are making them more vulnerable to poorer physical and mental health.
As it is, Malaysia’s overarching legal framework criminalises sexual practices, behaviour and identities of LGBT persons and increases their risks to persecution, arrest, detention, violence, and abuse. Just as these laws prevent LGBT people from seeking help and accessing justice, they also prevent LGBT people from seeking treatment and accessing healthcare. Furthermore, the laws and stigma are often used to justify prejudices towards LGBT persons, even in medical facilities.
Over the last year, we have seen Malaysian doctors make hateful and misguided public statements towards Lesbian, Gay, Bisexual, and Transgender (LGBT) people. Case in point, in August 2018, a doctor made a controversial statement that sparked conversations regarding medical ethics of healthcare providers in treating LGBT patients. These doctors associated LGBT people with a ‘deviant lifestyle’ and high HIV prevalence, implying that the LGBT population is immoral, irresponsible, and spreading diseases. They were simply reinforcing the stigma, discrimination, and alienation that LGBT Malaysians already face everywhere else in Malaysia.
It goes without saying that when the health of vulnerable populations is not taken care of, the health of the general population is impacted too. As Malaysian AIDS Foundation chairperson Dr Adeeba Kamarulzaman pointed out in her response to one of the doctors mentioned above, “While the rest of the world is talking about the possibility of ending the AIDS epidemic, it is people like you, and even worse, a doctor like you who makes this epidemic worse, because you deter people from coming forward for help and treatment.”
THE SHAME OF DOCTORS
Just in case you think the discrimination is all perceived, as if it is just in the minds of the patients, studies have shown that medical practitioners DO discriminate. In a recent groundbreaking study, “Factors Associated with Medical Doctors’ Intentions to Discriminate Against Transgender Patients in Kuala Lumpur, Malaysia” (Vijay A, et al. 2018), a total of 436 physicians at two major university medical centres in Kuala Lumpur, Malaysia, completed an online survey. The survey aimed to understand the way in which stigma and personal views held by medical professionals affected services provided to trans people. The results were astounding.
Amongst the LGBT, transgender and gender non-conforming persons are most frequently targets of discrimination. They have a higher prevalence of mental health issues and suicide, and are less likely to have health insurance, financial resources or means than others. According to the study, “Due to transgender stigma, physicians may feel shame as a consequence of having a transgender patient or transgender colleague. Physicians may also believe that transgender people do not deserve good care, leading to poor delivery of care. Given the high global burden of HIV among transgender women (i.e., high prevalence of HIV compared to other at-risk groups, including Men who have sex with men [MSM] and persons who inject drugs [PWID]), providers may be prejudiced against transgender women and be afraid of contracting HIV from transgender women, which may in turn contribute to discriminatory treatment. Physicians may also hold stereotypes about transgender people, such as the belief that all transgender people are promiscuous and do not care about their health, which could further contribute to discriminatory treatment.”
The report shows how existing social stigma towards trans people contribute to Malaysian medical doctors’ intentions to discriminate against transgender patients. The conclusion might seem obvious: Medical doctors who felt more fearful of transgender people as well as more personal shame for being associated with transgender people expressed greater intention to discriminate against transgender people. Meanwhile, doctors who endorse the belief that transgender people deserve good care, reported lower intent to discriminate.
WHERE THEY CAN TALK OPENLY WITHOUT FEAR OR SHAME
Even the Ministry of Health had been complicit in promoting discrimination. In 2017, the Ministry of Health launched a video competition which originally included a category for addressing those with “gender confusion”, as they put it, unhelpfully reinforcing the fact that LGBT people are mentally unsound and confused and needs fixing.
Psychologist and mental health advocate Dr Chua Sook Ning of Relate Malaysia, responding to the Ministry of Health’s guidelines, explained that: “By promoting such views, the competition put LGBT youth and youths who are questioning their sexuality at greater risk for poor physical and mental health. It is well documented that negative attitudes towards LGBT put these youths at risk for being victims of violence and a greater risk to die by suicide. […] The stresses experienced by these youths also puts them at greater risk for depression and engaging in risky sexual behaviours, because they lack a safe and accepting learning environment where they can talk openly without fear and shame.”
The public outcry in relation to the video competition compelled the Ministry of Health to engage with LGBT and human rights groups, resulting in changes to the guidelines to be more neutral. This is the kind of engagement and listening to LGBT and human rights groups that we have been asking for in the first place. It is the critical step in dismantling the discrimination, reducing disparities, and enabling access to life saving services.
We need to create opportunities to understand the lived experiences of LGBT people. Without the space to talk honestly about their health and experiences, LGBT people will continue to face higher levels of physical and mental health problems compared to other sectors of the population.
Instead, the government chooses to listen to the people who propagate marginalisation when it comes to the health of the very people who are being marginalised. That is like consulting wolves on the rights of lambs. Therefore, the government continues to spend public funds for ‘rehabilitating’ or ‘curing’ LGBT people of their sexual orientations and gender identities or expressions. This only perpetuates the perception of discrimination and justifies the distrust of LGBT persons towards public institutions. Funds and effort should be spent to improve access to health, training healthcare providers to be more sensitised, researching the impact of discrimination on the health of LGBT persons, and engaging with LGBT persons themselves.
It does not help that Malaysia’s new government has put out a series of mixed messages on where it stands with regard to the rights of the LGBT Community. Such mixed messages from the government prolong the negative attitudes held by medical providers, effectively increasing burden to the healthcare system. Ministers, politicians and healthcare providers in making public statements and public policies in relation to LGBT persons should be guided and informed by evidence and lived experiences of LGBT people. Acceptance of LGBT people into health systems, communities, and civic life is a vital step towards a more vibrant, healthy Malaysia.