Original Article

Are we being trained to discriminate? Need to sensitize

doctors in India on issues of gender and sexuality
Harshit Sharma, MBBS

Research scholar, Center for Psychiatric Neuroscience

The Feinstein Institute for Medical Research, Manhasset, New York

Corresponding Author:
Harshit Sharma
499 Stonytown Road, Manhasset, New York 11030, USA
Email address: harshit.sharma16 at gmail dot com

Received: 15-MAR-2018 Accepted: 05-SEP-2018 Published Online: 15-SEP-2018

Abstract
Even though the struggle for LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer,
Intersex, Asexual; with the + indicating myriad others) rights is an ongoing one, we
have come a long way in terms of acceptance and inclusion. In spite of the progress,
the LGBTQIA+ community in India still faces rampant bias in society as well as in
healthcare. This is fueled by misinformation, which leads to prejudice and violence
against these individuals. This paper discusses this struggle, touching upon the legal and
social aspects. The focus is on the detrimental effects of stigma on health outcomes and
health disparities for LGBTQIA+ individuals. The outlook of some in the medical
fraternity and the deficiencies in medical training, including redundant and outdated
curriculum/ textbooks, are discussed. It is implied that these factors result in biased and
ill-informed doctors who are poorly equipped to meet the health needs of the LGBTQIA+
population. Correcting the deficiencies is a priority in the face of the recent ruling by
the Honorable Supreme Court of India striking down Section 377 of the Indian Penal
Code that previously criminalized consensual carnal intercourse among consenting adults
of this community of people.

Keywords: Gender identity; Healthcare disparities; Legislation; LGBTQIA+ people;

Medical education, undergraduate; Section 377; Sexual and Gender Minorities;
Transgender persons

Introduction Lesbian, Gay, Bisexual and Transgender,

We have come a long way in terms of Queer, Intersex, Asexual; with the +
acceptance and inclusion, however, indicating myriad other identities.[1] The
rampant bias towards the LGBTQIA+ terms Lesbian and Gay denote same sex
community still exists, in society as well physical/romantic attraction, the former
as in healthcare. LGBTQIA+ stands for for women, and the latter for people of

Cite this article as: Sharma H. Are we being trained to discriminate? Need to sensitize doctors in India on
issues of gender and sexuality. RHiME. 2018;5:35-43.

www.rhime.in 35
all gender identities, but usually men. variant of human sexuality, a status that
The terms in the public health literature was accepted in 1990 [5]. The DSM – III
are MSM (“Men who have sex with (Diagnostic and Statistical Manual of
men”) and WSW (“Women who have sex Mental Disorders) held the last relic of
with women”) - referring to individuals pathologized alternate sexuality in the
who engage in sexual activity with form of Ego Dystonic Homosexuality,
members of the same sex. [2] The term which was removed in its 1987 revision
bisexual denotes physical/romantic (DSM – III R) [6]. Open acceptance of
attraction toward both men and women, homosexuality by the medical community
while “queer” is an umbrella term used paved the way for legal and cultural
for non–conforming identities. The fourth shifts in the western world. It deprived
term in the abbreviation stands for the opposing authorities of medical or
transgenders – these are individuals scientific rationalization for
whose gender expression does not discrimination.[7]
conform to the sex assigned at birth.[3]
They must be differentiated from Intersex Similarly, in the DSM–5 (2013), “gender
individuals, who naturally (without dysphoria” replaced “gender identity
intervention), develop primary and disorder” and explicitly stated that
secondary sex characteristics that are “gender non-conformity is not in itself a
ambiguous. Finally, asexual people, in mental disorder”,[8] shifting the focus
general, are those who feel no sexual entirely to the distress that many
attraction at all – this is different from transgender people face as a result of
celibacy in that celibacy is a deliberate their gender non–conformity. It is more
choice.[1] this distress, and not their identity so
much, which leads them to seek medical,
These are all independent of each other: surgical or psychiatric help.
biological sex (sex assigned at birth),
gender identity (a person’s innate The shaky legislative journey
identification as a man / woman / The battle for equal rights in India has
transgender / other), gender expression seen both highs and lows in a short span
(external manifestation of gender identity of time. Section 377, an archaic law
which may or may not conform to banning the act of “sodomy”, and
societal norms), and sexual orientation modeled on the British-Indian Buggery
(one’s physical, romantic or other Act rooted in 1533 English law,[9] was
attraction or non-attraction to other reinstated by the Supreme Court of India
people).[2] Failure to grasp the concept in December, 2013 after being struck
that these are separate things leads to down by the Delhi High Court in
discrimination in society, and in the legal 2009.[10]
and healthcare systems. Individuals
belonging to different subclasses of the In August 2017, The Supreme Court
LGBTQIA+ community face a very found that Right to Privacy and the
different set of challenges, but what ties protection of sexual orientation lies at
them together is the stigma and its the core of the fundamental rights
adverse consequences. The latter are guaranteed by the Constitution, and
discussed together in this article. noted that sexual orientation is an
essential attribute of privacy.[11] A five
The Global Perspective judge bench of the Supreme Court then
The World Health Organization (WHO) decided to reconsider the 2013 judgment,
accepts homosexuality as a normal and gave the verdict on September 6,

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2018, stating that Section 377 was in stressors (like the experience of
violation of fundamental rights.[12] discrimination and violence) and proximal
stressors (like expectation of rejection,
Another landmark judgment (NALSA concealing true identity, and internalized
judgment) was passed by the Supreme homophobia).[17] These have been linked
Court on April 15, 2014, which upheld to poor mental, sexual and physical
the legal right of an individual to self- health as well as decreased access to
identify gender identity as health care for minority populations.[18].
male/female/transgender without having LGBT individuals are 2.5 times more
to first avail medical and surgical likely to experience depression, anxiety,
treatment.[13] This allowed male and and substance misuse compared with
female-identifying transgender people to heterosexual individuals.[19] Twenty
recognize themselves as ‘transgender’ and percent of sexual minority adults have
to do so legally. attempted suicide - in comparison, the
rate is four percent for the general
The Supreme Court directed the Centre public.[20]
and State governments to formulate
welfare schemes, employment and The minority stress model has been
education related schemes, rehabilitation adapted and studied in the Indian
and healthcare access schemes, and context, including an examination of
reservation policies for transgender disparities in health of these groups.[21]
people. Unfortunately, the Data from quantitative and qualitative
recommendations of the judgment were studies has shown poor mental health
watered down significantly in the outcomes in these populations, with
Transgender Persons (Protection of disproportionately high rates of stress,
Rights) Bill 2016 introduced by the depression, anxiety, suicidality and
Ministry of Social Justice and substance abuse. [22-24] Poor
Empowerment.[14] It deviated psychosocial health has further been
significantly from the aspect of self- linked to sexual risk-taking and a higher
identification, by recommending the setup prevalence of HIV in these
of a screening committee to make populations.[25]
determinations on an individual’s gender.
Negative attitudes can prevent optimal
Stigma leads to disparities in utilization of healthcare services. Studies
have shown physician homophobia to be
health for minority groups a barrier to health care, with LGBTQIA+
Homosexuality is still a taboo in many patients being more likely to delay or
communities and is deemed as avoid care due to fear of harassment or
unacceptable by many religious and discrimination.[15-17,26] There are
social sects across the country.[15,16] limited studies from India, but they
Both MSM and transgender individuals detail the discrimination faced by
face systemic discrimination, social members of the transgender community;
victimization and violence (both physical for instance, there are reports of trans-
and sexual).[16] Such discrimination and women being given male gowns and
its negative health consequences have being placed in male wards.[26,27].
been widely studied in Western literature.
According to the “Minority Stress According to the Joint United Nations
Model”, members of sexual or gender Program on HIV and AIDS (UNAIDS),
minority groups may experience distal transgender women are 49-times more

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likely to acquire HIV than the general In July 2018, the Indian Psychiatric
population.[28] Among transgender Society took a similar step forward by
individuals in India, condom use remains issuing an official statement about “same
low and almost two-thirds report no sex sexuality” being a “normal variant of
access to treatment for sexually human sexuality much like
transmitted infections; around half were heterosexuality and bisexuality”. They
referred for HIV testing and up to 67·1% further went on to state that “there is no
had not been given proper counselling on scientific evidence that sexual orientation
antiretroviral therapy adherence.[29] can be altered by any treatment” and
While the Supreme Court of India, finally strongly supported the
through NALSA, had directed “decriminalization of homosexual
governments to set up HIV screening behavior”.[34]
centers specifically for the trans
population, this was left out of the 2016 Among some of the positive steps taken
Transgender Persons (Protection of by the state governments, Tamil Nadu
Rights) Bill.[13,14] Novel interventions to and Kerala are the first Indian states to
prevent HIV transmission, like PrEP (Pre- introduce a transgender (hijra/aravani)
Exposure Prophylaxis), have gained welfare policy under which transgender
popularity in the West but are not widely people can access free sex reassignment
distributed in India. In a qualitative surgery (SRS) in government hospitals
study in Indian MSM, stigma related (only for male-to-female) and get proper
concerns were suggested to be a barrier documentation issued. The transgender
for PrEP uptake in the country.[30] welfare board in Tamil Nadu has
representatives from the transgender
Opinions and practices of community.[35]

medical practitioners Other practices have come under scrutiny

In the past, there have been statements for their discriminatory policies. Blood
from senior psychiatrists calling banks of prominent hospitals have been
homosexuality “not natural” and a “grey reported to “ban” homosexual people
area in Psychiatry”.[31] There is a from donating blood, or discourage
prevalence of conversion therapy for participation by inquiring about sexual
“treatment” of homosexuality, with orientation during the screening
practitioners asking large sums of money process.[36]
for the same. Such practitioners have also
been known to propagate baseless notions
about hormonal, genetic and Knowledge gap in trainees
psychological “reasons” for Data on physician attitudes towards
homosexuality, and they offer aversive homosexuality in India is very limited. A
therapy, electroconvulsive therapy, study of 244 medical students and interns
psychotropic medication and even showed an insufficient knowledge of
religious texts to guarantee time bound, homosexuality. For example, the
complete conversions.[32] The WHO has statement “Greece and Rome fell because
issued a statement condemning such of homosexuality” was incorrectly
therapies for lack of any medical identified as true by 191 (78%) students.
justification and stating that they In agreement with preceding work, the
“constitute a violation of the ethical above study also noted an increase in
principles of healthcare and violate positive attitudes with better
human rights”.[33] knowledge.[37] A study on 212 dental

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students measured regard for patients of their inclusion in the
from often-stigmatized populations, curriculum.[43,44] In one study,
through different stages of their participants (postgraduate medical and
curriculum. According to the study, the dental residents), ranked internet and
least positive regard was noted for newspaper sources higher than medical
patients with LGBT identity, and there textbooks as sources of their ethics
was no significant shift in different stages knowledge.[45] Probably the greatest
of training.[38] evolution in LGBTQIA+ perspective has
been in the discipline of Psychiatry, and
Deficiencies in education and so, such discussions could be a part of
the Psychiatry curriculum - currently the
training topic is inadequately addressed during
Such results are not surprising in the undergraduate medical training.[46]
context of the outdated medical
curriculum.[39] Widely followed textbooks
have come under criticism for Recommendations for the future
pathologizing and criminalizing The Medical Council of India (MCI)
homosexuality and transgender announced its plans for a revised and
identity.[40] Multiple textbooks on updated medical curriculum, to be
Forensic Medicine and Toxicology, which implemented by 2018. Among other
have previously also been criticized for things, it is to focus on “professionalism
insensitive discussion of sexual violence and ethics” as well as “sexual health
against women, also often portray issues”.[47] This is a step in the right
distorted views on the LGBTQIA+ direction, as it may teach students about
identity.[41] Archaic terms such as sexuality, sexual risk-taking and how to
“pederasty” and “tribadism” are take a sexual history. However, many of
discussed in conjunction with bestiality the problems (including stigma) faced by
and pedophilia, reinforcing negative LGBTQIA+ individuals aren’t necessarily
stereotypes. A widely followed textbook “sexual” in nature.
of undergraduate psychiatry enlists
methods like psychotherapy, aversion The American Association of Medical
therapy and even androgen therapy for Colleges has recommended wider
changing a person’s sexual orientation. inclusion of LGBTQIA+ topics, dedicated
Similar methods are suggested for teaching time, clinical exposure to
“Reconciliation with the anatomic sex” LGBTQIA+ patients, and faculty training
in transgender individuals.[42] to impart trainees with the required
knowledge and clinical skills. They have
Such negative characterizations and also stressed on the importance of a safe
outdated treatment guidelines have little and healthy learning environment, free
basis in current medical literature and from judgment and discrimination.[48]
they misinform medical students. This may be especially relevant in light
Discussions about patient confidentiality, of institutions composed of individuals
clinical etiquette and the importance of from a variety of socio-cultural
an aware, non-judgmental worldview backgrounds, with their own implicit
could be included in the curriculum by attitudes and biases. Anti-discriminatory
introducing newer subjects like medical policies and anti-harassment policies are
ethics and medical humanities. However, yet to be formulated and implemented by
there is dearth of these subjects in both the MCI for Trans and Queer
undergraduate and post graduate professionals and students in the medical
education in spite of arguments in favor fraternity.

www.rhime.in 39
 healthcare should be given to all patients
A good way to encourage discussions
irrespective of sexual or gender identity.
about these issues could be to include
medical humanities in training which
would include the study of literature, art
and history. As discussed, medical ethics
Conclusion
Considering the legal battles, social
should also be more prominently featured
stigma and the resulting negative physical
in the curriculum. Hopefully these
and mental health outcomes among the
subjects would impart learning about the
members of the LGBTQIA+ community, it
constantly changing culture, raise
becomes all the more important for
questions about ethical conduct and
health care providers to have adequate
foster a sense of compassion and
knowledge and develop positive attitudes
awareness of the human struggle.
towards these individuals. It is warranted
that we step-up our efforts in training
It may also be beneficial to give more
doctors who can not only save lives but
time and weightage to Psychiatry,
can also be well-rounded and well-
considering the evolution of LGBTQIA+
informed, progressive thinkers. The
diagnosis in Psychiatry and the poor
scientific community has always served
mental health and identity struggles of
an important role in shaping people’s
the community. More medical students
opinions about phenomenon which defy
and doctors should take up research on
existing societal norms. With the
LGBTQIA+ topics so as to clarify the
Honorable Supreme Court’s favorable
stance of the medical fraternity on this
verdict on Section 377, it is high time
population. For practicing clinicians,
we publicly address issues of gender and
CMEs and online training could be a
sexuality so as to reduce ignorance and,
good way to sensitize them to LGBTQIA+
hopefully, pave the way for legal, social
issues and bring them up to speed about
and health policy reforms targeted
hormonal and surgical treatments for
towards betterment of this marginalized
transgender individuals, prevention and
community. The hope is to reach a place
treatment of HIV/other STDs, and other
where doctors focus on specific health
health needs of LGBTQIA+ patients. The
problems that LGBTQIA+ individuals face
basic message is that appropriate,
instead of pathologizing and
comprehensive and compassionate
discriminating against their identities.

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