- Local report highlights issues faced by the community in accessing the healthcare sector, including mental health services
Discrimination faced by Sri Lanka’s lesbian, gay, bisexual, transgender, intersex, and queer and questioning (LGBTIQ) community members remains prevalent in several areas of the health sector across the country. While certain areas such as sexually transmitted infections (STIs) prevention and care have evolved with more awareness, other areas in the healthcare sector await further progress.
Exhausting experiences, stigma and judgement, and limited services have led to a negative perception of healthcare services. Brain drain, limited resources, and weak mechanisms are some of the challenges that healthcare service providers face today from their point of view, while the training offered to them covers a limited number of topics, and the mechanism for updating knowledge remains inadequate.
Noting this, a study report issued by local human rights organisation Equal Ground this week in Colombo pointed out that at present, there is only human immunodeficiency virus (HIV)- and STIs-related training when it comes to topics that discuss the LGBTIQ community, while there are challenges concerning mental health services sought by the community as well. Titled “Access to healthcare services for the LGBTIQ community in Sri Lanka”, the report was based mainly on discussions and interviews with LGBTIQ persons, healthcare service providers, and experts. The study focused on the above-mentioned situation in the Colombo, Kandy, Polonnaruwa, Galle, and Jaffna Districts.
LGBTIQ persons and health professionals
The study findings showed that overall, the LGBITQ community has a thorough understanding of sexual health, and that they have received this education through clinics and non-governmental organisations (NGOs). Due to this, the report added, LGBTIQ persons actively ensure that they are sexually healthy and undergo frequent check-ups.
As per the findings, the LGBTIQ community does not view being HIV positive as an all-consuming health concern, and instead flags mental health as a bigger issue. With regard to mental health, the report read: “Frequent and widespread abuse, the lack of familial and societal acceptance, unsustainable relationships, employment issues, and economic problems result in mental health challenges. They understand these mental health problems and attempt to solve them through their own remedies.” However, the study had observed that seeing a therapist or a psychiatrist was not a spontaneous decision concerning mental health, and that LGBTIQ persons only view a psychiatrist as a point of contact to obtain the gender recognition certificate (GRC) and evaluation, and not as a source of support.
The study analysed LGBTIQ persons’ attitudes towards the healthcare system through the point of view of a service receiver, which pointed out exhausting experiences, stigma and judgement, limited services, brain drain, limited resources, systems of prioritisation, a weak mechanism to update knowledge, and training covering only selected topics.
Discrimination faced by health service seekers in encounters with doctors – as per LGBTIQ persons – includes the absence of basic knowledge and awareness about the LGBTIQ community, associating the LGBTIQ community with commercial sex work and STIs, unnecessary questioning and unsolicited advising, physical examinations without proper consent, and sexual harassment.
In encounters with psychiatrists, discrimination faced by LGBTIQ persons includes being forced to remain cisgender (someone whose internal sense of gender corresponds with the sex that the person was identified as having at birth) and heterosexual, violating privacy, verbal and mental harassment, and delays in issuing the GRC. Discriminatory acts by surgeons included the refusal to perform surgeries.
Discrimination faced by health service seekers in encounters with nurses included degrading treatment, mistreatment, prejudice-based assumptions before treating LGBTIQ community members, the non-recognition of their identity and rights, and the exposing of community members. Moreover, the report explained that discrimination faced by health service seekers in encounters with hospital attendants include verbal harassment, making a spectacle of health service seekers, hostile treatment, sexual objectification, and exploitation.
The report further discussed the manner in which LGBTIQ persons are treated in public and private healthcare service-providing facilities.
Recommendations
The report noted that the healthcare system can be equipped to better serve the LGBTIQ community through a number of measures.
Among them were introducing effective complaint redressal systems; establishing predetermined guidelines for the admission of patients – especially those who identify as transgender, intersex, or are doubting their gender; the continued digitisation of patient records and registration using personal health numbers (PHNs) and quick response (QR) codes; providing comprehensive training to healthcare professionals on how to assist and support LGBTIQ health service seekers; establishing gender neutral restrooms, waiting rooms, and wards that do not have separate male and female partitions; ensuring inclusivity and preventing discrimination and distress; and using pharmacists for knowledge dissemination.
Under the recommended key points of intervention, the report said that geographical areas which are known to have populations that are tolerant of the same should be utilised for pilot programmes, in turn creating expectations for other areas to follow. Adding that areas with people that are more open-minded to new concepts have more of a potential to accept LGBTIQ community-related advancements, it was explained that these areas can be utilised for pilot programmes that will raise the expectations of community members in other closed environments.
A concern raised in the report was that areas that are close-minded by its culture and history are less prone to change. Adding that drastic system modifications for the LGBTIQ community in these areas have the potential to receive backlash and create long-lasting negative impacts, the report said that in this context, it is important to take cultural nuances into consideration.
Drivers that will bring greater openness and acceptance in such close-minded communities, as per the report, are, government-led communication campaigns using local champions and influencers from those cultures to improve awareness and acceptance about the community, local cultural myths that foster notions of inclusivity and non-discrimination embedded as part of local art and culture (e.g. street drama, puppet shows during local festivals, and events), sensitising programmes under various village-based clubs and societies (e.g. youth society, welfare society), building online and over-the-phone regional consultations, counselling and therapy spaces that safeguard anonymity and protects against harassment, government recognition and awards for cities that promote inclusivity and equality, and having an occupational quota for LGBTIQ persons in government positions based on the right qualifications to improve respect and recognition.
The report underscored the importance of providing education from a young age, regarding which it was recommended to include lessons related to gender identity and sexual orientation in a child-friendly manner to curricula, promoting school counselling for those who identify themselves as LGBTIQ or for those who need clarity, and sensitising programmes for children and parents.
The report noted that explaining one’s gender identity and sexual orientation when admitting oneself to a hospital is a hassle, and that therefore, minimising such difficulties is essential. In this regard, it recommended pre-determining where to admit a patient, continuing the digitisation of patient records and registration, follow-ups and future appointments being handled using QR codes online, and online follow-up and medical monitoring systems.
With regard to training staff members of and providing facilities at healthcare service-providing institutions, the report recommended that such institutions should have trained, sensitised staff to handle admissions of LGBITQ persons and to provide training for healthcare service providers to guide LGBTIQ health service seekers. It added that general washrooms without segregation as male or female would sufficiently avoid discrimination and discomfort.
Moreover, adding that individuals that were subjected to abuse and discrimination inside healthcare facilities were not delivered justice and that patients should know where to go and to whom to complain to in the face of injustice, the report discussed the importance of establishing a powerful complaint and redressal system. Among the recommendations that were presented in this regard were assigning a person and system to handle complaints and provide redressal, having in place a quick feedback and rating system for each healthcare service provider and facility that the patient must go through, and informing patients about their rights towards any discrimination and how they can gain legal support.
“A dedicated service centre enables health service seekers to avoid discrimination in the short run. Yet, it is not a sound solution in the long run as such specialised services further distance community members from the general public,” the report said, adding that such a facility should be named in an unsuggestive manner and maintain the privacy of all patient records.
Improving medical professionals’ standards
Based on the study findings, the report put forward several suggestions to improve the standards of psychiatrists, counsellors, surgeons, surgical counsellors, nurses, attendants, security personnel, and pharmacists.
In the case of psychiatrists and counsellors, the report said that while their current belief system includes prejudices and stereotypes and also the belief that they cannot change the hospital environment to better suit the health service seekers’ needs, ideally, among other measures, taking proactive measures to improve the hospital environment – including improving facilities to protect privacy – is recommended. It added that all licensed psychiatrists must be LGBTIQ-friendly, and aware of their medical needs, requirements, and the support that is to be provided.
The lack of consistency in the GRC and providing services only when a health service seeker visits them were identified as behaviour-related challenges, regarding which the report said that ideally, the GRC should be delivered in a reasonable time frame, and that the progress and reasons for delays and the next steps of the GRC process should be communicated to the transgender person. It further recommended to prevent attendants or other intermediary parties delaying the GRC process without acceptable reasons.
Regarding the role of surgeons and surgical counsellors, the report said that while the present perception is that their current knowledge and experience are adequate and up to date, Sri Lankan surgeons should be ready for new information, knowledge, experience, and exposure. A behaviour-related challenge identified in this context is such professionals’ weak proactive learning about surgeries required by the LGBTIQ community.
Discussing challenges concerning nurses, attendants, and security personnel, the report pointed out a lack of understanding and care towards some health service seekers, and prejudice-based assumptions before treating community members. In this regard, it was noted that health service seekers deserve equal respect, empathy, and care, while open-mindedness is required to address each health service seekers’ unique situation. Insensitive behaviour towards the community – such as name-calling and violating privacy – was recognised in the report as being among behaviour-related issues, regarding which respect for all service seekers was emphasised.
What is more, the role of pharmacists in knowledge dissemination was discussed in the report. In this regard, the report revealed that the LGBTIQ community shows preference to obtain support from pharmacists over going to a hospital, and that in some cases, it has been reported that pharmacists provide unofficial treatment for monetary gain. In a context where pharmacists who have gained the community’s trust have the power to disseminate knowledge and guide it towards the right medical support and experts, the report added, it is important to provide knowledge and training to pharmacists.