Healthcare challenges faced by LGBT community in India: In conversation with Vinay Chandran

Vinay Chandran, Counselor and Executive Director of Swabhava is studying LGBT (Lesbian, Gay, Bisexual and Transgender) community and its access to healthcare in South India: the states of Kerala, Tamil Nadu, Karnataka, Telangana and Andhra Pradesh. This study is a part of a study by TATA Institute of Social Sciences in an attempt to understand the discriminations faced by the LGBT community in different domains – education, housing sector, healthcare and public spaces across India.

Started in 1999, Swabhava works to provide access to support services and counselling to members of the LGBT community. Swabhava has a helpline called Sahaya and an in-person counseling service. The organisation provides support information about coming out of the closet about one’s sexuality, family, relationships, and workplace, among others. It also provides referrals to doctors, counselors, access to support groups, be it for LGBT or queer adults. Hidden Pockets caught up with Vinay Chandran to know more about this study on LGBT community and their access to healthcare and share some of the findings of this study with our readers.

About the study

Hidden Pockets: What is the expected outcome of this national study on health related problems faced by the LGBT community?

Vinay Chandran: The overall project on LGBT discrimination is an exploratory study. It is about trying to find out the experiences of discrimination that the community faces in the country. It is important to record these experiences simply because the Supreme Court talked about LGBT community being a miniscule minority during the Supreme Court hearing against Section 377. This was cited as the reason to read down Section 377. This resonates with why we need to collect this data.

Hidden Pockets: What do you think would be the number that will make them (Supreme Court) recognise the LGBT community as an entity?

Chandran: It is not about that. The point is that the affidavits and other reports haven’t used the existing statistics and data properly. So we want to be able (at least in my case), to flood the market with this information about the discriminations faced. The conversation around discrimination right now is heavily focused on the LGBTQ sector and their legal rights. But this can also be seen as a systemic discrimination in the society and its functioning. Therefore there is more to it than just being abused by the law. It is a systemic thing and this adds to that questioning (of the system).

Hidden Pockets: What is this healthcare project focused on?

Chandran: Be it generic healthcare, seeking mental health services for LGBT people in terms of counseling and so on or accessing surgery without having prejudice thrown at them, we are looking at how the different mental health and medical health services interact with LGBT people and how we can improve that interaction and improve the experiences of LGBT people in that context.

Challenges faced by the LGBT community

Hidden Pockets: From your experience, what would you say are some of the challenges that the community faces with respect to accessing healthcare?

Chandran: See healthcare itself is not a priority for LGBT people simply because of the fear of what it might entail. The context where medicine and LGBT meet could be in terms of sex reassignment, gender reassignment surgeries, sexually transmitted infections and mental health.

We have heard enough stories of the issues that transwomen face. I don’t know about transmen experiences but a lot of transwomen refuse to go to medical colleges for treatment. They say we don’t want to go to medical colleges even if they have a chest cold or a cough because the immediate response from the doctor is – ‘Take off your clothes, call the students and say this is what a trans woman looks like.’ They do this to their bodies without even asking their permissions. This is problematic because government medical colleges are the cheaper medical places for them to go to. Most of the people if you’re LGB (Lesbian, Gay and Bisexul) for instance can pass (without being questioned about their sexuality) if it is a cough or cold but not transwomen.

You can be a gay man asking help from a doctor and your sexuality wouldn’t matter but if it is a Sexually Transmitted Infection (STI), which is another contact point, then you’re talking about doctors’ attitudes. One person we spoke to, went to a doctor with a STI and the doctor asked him if he was married and when he said no, the next question was if he had gone to a sex worker. The doctor asked nothing about other sexualities. When the client actually said that he’s gay, the doctor replied, ‘agh that’s why you’ve got it (STI). You stop that you’ll stop getting this.’ The sense is that if you are gay then it is automatic for you to get STIs. It proves whatever prejudice they already have in their minds.

Hidden Pockets: What problems do women face and trans men face with respect to accessing healthcare or sexual health services?

Chandran: I don’t have a lot of data about that. Bina Fernandez has done some work on the issues faced by women. She talks about lesbian and bisexual women accessing mental health and the kind of prejudices that doctors have more so because they are biologically female. Therefore the idea of reproduction and the need to reproduce also comes into the picture. Ketki Ranade has another paper in which she also talks about the same issues that lesbian, bisexual women and some among trans men face. In one particular context, a gynaecologist obstetrician who has otherwise good records of supporting trans women and trans issues refused to do hysterectomy on a biological woman who is trans man because he doesn’t believe in removing the uterus of a woman who has not enjoyed motherhood. The fact is that the transman has no desire for that body. But that is irrelevant to the doctor. He understands removing penis and testicles for a trans woman and recognizes the need to provide that surgery. But with a transman, he refuses to do the same.

LGBT community and access of the healthcare

Hidden Pockets: How does section 377 affect the LGBT community with respect to accessing health care?

Chandran: There are doctors who say that ‘if there is a law, you have to worry about the law’. There are doctors saying that I don’t want to become an abettor to a crime. But by and large doctors understand their ethical duties. Even if they provide fake treatments (to treat homosexuality), they keep quiet about it. If they publish it in a paper, they mention that treatment was provided and the patient successfully got married.

Hidden Pockets: Is it legal for a doctor to refuse treatment because someone is LGBT?

Chandran: There are doctors who can do that to anything, not just LGBT. There is no policy in India that addresses discrimination of LGBTQ people. NALSA judgement in 2014 (on transgender rights) is the first place where they’ve actually spoken about transgender people. They’ve tried to add sexual orientation but I don’t think the government is going to address it. However it’s the first time that kind of discrimination has been spoken about and the HIV AIDS bill addresses it in the context of HIV. There’s no other context where specifically someone says you cannot be discriminated against on the basis of sexual orientation or gender identity. We can start that conversation because of NALSA judgement.

Hidden Pockets: What is the cost of accessing SRS services for trans women? Which are the states where SRS services are available?

Chandran: Each state is very different. It depends on the kind of services that are available. Some hospitals offer subsidized services and some hospitals offer full services. In terms of government SRS services, it is only available in Tamil Nadu, among the Southern states. There is no recognized service center anywhere else that I have seen (in Southern India). NALSA judgment hasn’t been implemented right across the country so we still struggle with implementation of basic policies for trans men and women.

LGBT community and mental health services

Hidden Pockets: How do you work around the clinical diagnosis of homosexuality as a disease or condition by several mental health practitioners in the country?

Chandran: This is changing. There are a lot of practitioners who have caught up with the fact that it is no longer right to prescribe treatment for being LGBT. In fact, we’re getting stories where we actually hear people say that the psychiatrists are now catching onto the game because they can actually make more money by supporting the LGBT community as opposed to prescribing treatment. But as expected, the prejudice against the LGBT community remains. However there is a lot of improvement. What we want to do is improve the experiences of the community members. So when we present the study, we are also talking about creating outputs like booklets (for all) with the kind of questions you might encounter and how to respond to them. On the other hand booklets for doctors and counselors would give information about the kind of problems that clients might come to them with, clients responses and what would be the ideal (responses).

Hidden Pockets: The Mental Health Bill of 2017 mentions that no one shall be discriminated on the basis of sexual orientation with respect to access to mental health care. How does this conflict with Section 377?

Chandran: This is not a new problem. Government of India has always had policies on the left and punishments on the right so it is really not a conflict as far as we are concerned. If you consider the National AIDS Control Programme (NACP), they have always had MSM (Men who have sex with men) friendly programmes and they also have section 377.

The conflict between the law and the policies

Hidden Pockets: How then can you also have section 377 when you have MSM friendly AIDS programs? How will people come out and say I have AIDS?

Chandran: You’re seeing it as a conflict. The government is not seeing it as a conflict. For them, on one side, the law will continue to do what it wants to do and on the other side, it wants to help. So it will continue to do so until it meets a block. During the UPA (United Progressive Alliance) government, the Department of Health, Department of Law and the State Department had no objection to removing Section 377 and that’s how the Delhi High Court passed its judgement in 2009. Despite that, we had a bad response from the Supreme Court because the Supreme Court judges were fairly homophobic. Now in the current argument, it has become a cultural issue with morality and value systems. Now they (government) don’t see having Section 377 and MSM friendly programmes as a conflict. Healthcare can do whatever it wants but the law will do what the law has to do.

Hidden Pockets: How open are MSMs as they call, to actually coming out and accessing these sexual health services? Is there no breach of privacy?

Chandran: There’s been a lot of work over the last 14-16 years with NGOs and all these Community Based Organisations (CBOs) that are especially working around HIV. The conflict is not there. The conflict is when it comes to law. There is no intentional breach of privacy. Let’s put it that way. People are not going out of their way to say I’m serving homosexuals, come and arrest me so the programmes are going on and they maintain confidentiality because its HIV. I’m assuming that most other departments will keep their hands off. I haven’t seen this in any policy so I’m just assuming that that’s how it is.

Hidden Pockets: Does that mean that they will not breach anyone’s privacy or ask for data?

Chandran: We don’t know. There’s not a written policy that says that they will not approach HIV organizations or that they will not touch them or go and infiltrate them.

Hidden Pockets: What kind of changes have you observed over the years with respect to looking at LGBT issues?

Chandran: As far as urban scenarios are concerned, there is a sense that a lot more people are familiar with LGBT rights narratives now and therefore are more cautious of providing that kind of (homosexuality curing) treatment facilities in urban scenarios. We don’t have full knowledge on what it is in rural areas. There are still people who offer treatment for homosexuality but they don’t do it openly. They don’t announce except if there is a religious backing to them. By and large in urban spaces, there is now some sense of awareness about the LGBT communities. So if a client comes to them and is LGBT then they are referred to us. This happens a lot more than it used to 15 or 20 years ago.

Where to get an abortion and other sexual and reproductive health services in Kolkata?

Recently Hidden Pockets set out to find different sexual and reproductive health (SRH) services in the city of joy, Kolkata. A primary research of the different health services provided in the city was done before the mapping exercise was undertaken. This research included Internet research and conversations with different individuals, activists and organisations working in the space of public health. The research showed that the status of public health services was inaccessible, unhygienic and crowded. So we decided to picked out a few of the available public health service providers in the city to understand the state of SRH services in the city. Since Family Planning Association of India (FPAI) usually features on our list of recommendations in the cities that we map, we decided to start with FPAI.

What happened to Right to Information?

The FPAI centre in Kolkata is located in Etally. The nearest bus stop is located at 5 minutes walking distance. The centre is located on the inside of a market road. It is a rather old building with a board outside that says Family Planning Association of India and lists all the services provided at the centre. It was hard to miss the strong smell of urine on entering the building premises. It wasn’t the cleanest of centres that we have been to so far, in the country. The first floor has the ward and the office is on the second floor.

On requesting for information about the services provided at the centre, the categorical response given by the medical officer was “Go to the Kolkata headquarters for any information about the services provided here. We will not give you any information.” The staff seemed clearly quite unapproachable. It was quite strange considering that the list of services provided at the centre is listed on the name board displayed outside on the door.

With FPAI off the list, it became important to look into other sexual and reproductive health service centres in the city that were approachable and also provided different services at a reasonable cost. More importantly, were there any reasonable government hospitals in the city providing SRH services?

How good are the government hospitals?

In an attempt to find some answer to that question, SSKM hospital, (located about half kilometer from Rabindra Sadan metro station) was chosen as the next destination. This is a referral hospital along with a medical college attached to it. Reason enough, the hospital is quite large and also usually crowded throughout the day. Located in the centre of the hospital campus, the gynecology department is difficult to locate without any support from the hospital staff. The guard at the gate was quite helpful giving directions to the gynaecology department. Gynecology department is located opposite to the Eye department and diagonally opposite to the Ronald Ross block. However, even with help, it was hard to locate considering the constant crowd on the hospital campus. It is a large department that has a separate building for the neonatal services provided at the hospital.

The cost of acquiring an OPD card in the hospital for all departments is Rs. 2. On checking the OPD registration desk on the ground floor of the building for services provided by the gynecology department and cost involved, we were told to check directly with the gynecology OPD. The administrative staff did not seem approachable. That said, the OPD registration had a constant queue throughout the day. The gynaecology OPD is a clean ward with air conditioning. On requesting from a doctor on duty (an intern), we were asked to talk to the Head of the Department (HOD) of Gynaecology whose office is in the Ronald Ross block. Though Ronald Ross block sounded easy enough, locating the HOD’s office in the building was not easy. The staff and interns that we spoke to, on the ground floor of the building either refused to give any information or said that they are not aware of the office. Being utterly confused in the large hospital, we had to check with several departments including Eye and ENT to be doubly sure of the HOD’s office. Due to sheer exhaustion of locating the different departments and heavy rains, we decided to meet the HOD on day 2.

Eventually on day 2, the HOD’s office was located on the second floor of Ronald Ross building. On landing up at the HOD – Dr. P.S.Chakravorthy’s office, we were asked to come the next day to have a conversation to understand all the sexual and reproductive health services provided in the hospital. Unlike other staff, the HOD was quite approachable and friendly. On day 3, an interview was conducted to understand the different SRH services provided in the hospital. The doctor was willing to answer all questions that were put forth.

Excerpts from the interview conducted:

Sexual and reproductive health services available for men:

“There is a STD clinic in the hospital close to the skin clinic that includes STI and RTI services as well.”

Process of accessing these services:

“The person has to go to the OPD STD clinic and register and see the doctor.”

Most common concerns for men:

“Mostly urethral discharge, burning sensation and gentile ulcers.”

HIV testing centre:

“There is one HIV testing centre that is attached to the blood bank, one to the microbiology lab, one to pathology department and there’s another attached to the antenatal clinc. There may be even more.”

Cost of accessing these services

“Buying the OPD card at Rs. 2 gives access to all services in the hospital including HIV testing centre at no additional cost, for both services and medication.”

AIDs & HIV related services:

“When we find that a person is HIV positive, we send them to the ART centre where they are provided counseling, both the patient and the spouse, medications, lifestyle advices, health education.”

Sexual and reproductive health services available for women

“Same as men and in addition, gynaecology OPD, skin OPD (because of wart). There is an adolescent clinic also – usually for teenage girls related to reproductive problems – menstruation – regular, irregular, pain, discharge etc.”

Medical Termination of Pregnancy (abortion): (Both married and unmarried women)

“We definitely provide abortion services to both married and unmarried women. To us, they are all patients. Irrespective of whether they are rich, poor, no matter the caste or creed, we try to help them.”

Cost of accessing this service

“Even MTP is included in the OPD charges of Rs.2, for MTP involving both medication or surgical intervention.”

SRS services

“The Plastic Surgery department runs the SRS service. It is again, free. In West Bengal, all services provided by the government are free. This also means that we have a lot of crowd here for all services.”

Other sexual and reproductive health services provided

“Family Planning services and Adolescent Friendly Health Clinics are also available.”

A reality check!

Though the doctor confirmed the availability a wide range of sexual and reproductive services, the concerns raised and expressed by people we spoke to accessing the services included:

  • Constant crowd
  • Need to have connections inside or outside the hospital to get access to high quality services
  • Often junior doctors or interns tend to the patient

On having spoken to the Plastic Surgery Department on the SRS service at the SSKM hospital provided in the hospital, Abhirup Kar, President of Civilian Welfare Foundation said, “The concerned person did not know what SRS was. We had to explain it to them and then  We had to explain it to them. We were then told that SRS is not done there and is only a subject of research in the hospital.”

Owing to the concerns raised about government institutions, we thought it necessary to also check with the private institutions on the different SRH services provided. Speaking to Hidden Pockets, a senior gynecologist* with 20+ years of experience said that the price of getting an abortion could range between Rs. 3,500 to Rs.30,000 in any private institution depending on the location. While the cost of getting an abortion could be anywhere between Rs.3,500 to 10,000 in Northern Kolkata, it costs Rs.15,000 to Rs.30,000 in Southern Kolkata depending on the institution and seniority of the doctor.

The senior gynecologist’s (hospital’s) cost breakdown for an abortion was as follows:

Rs. 4,000-5,000 for consultation

Rs.1,000-2,000 for the services

Rs.1,000 or so for medication

____________________

Total: Rs. 7,000-9,000  (cost estimated for his hospital’s services)

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Note: Hidden Pockets studies focus on recommending at least one SRH service provider in any city that we go out after personal assessment of the centre for different parameters. However in Kolkata, owing to the crowd and unfriendly staff, we could not go beyond 2 government service providers during our time there. 

PS: “FPA India clinics may charge, what we prefer to call as a ‘partial user fee’ to the clients for seeking abortion or any other SRH service. This fee is very subsidized and helps the Association meet some running costs. However, all FPA India clinics also have a “NO REFUSAL POLICY”, which states that no client walking into any FPA India facility is denied any service, especially if he/she is unable to afford even the subsidized fee. Thus, poor and marginalized clients can also access quality services in FPAI clinics. Only when the facility is not equipped to provide a particular service (for example some client may need a specialized service, or admission or higher level emergency care) are clients to other facilities.”