Mainstreaming: Best Option for LGBTQ Healthcare?
Is our prevailing healthcare delivery system equipped to cater to the needs of sexual minorities? Alpana Dange, a seasoned researcher delves into the topic.

In a plural and thriving democratic country like India, mainstreaming is a very popular terminology. In sociological and political parlance this refers to bringing marginalized groups of people who by the virtue of their caste, religion or economic backwardness are not able to enjoy their rights and entitlements like other citizens; therefore it is a systematic process to involve and support them to claim their rights as equal citizens of India.
While at one level, there is more visibility to LGBTQ people on account of their ongoing efforts of collectivization and assertion of equal rights, at another level i.e. mainstream healthcare sector, they largely remain invisible due to the stigma surrounding their sexual orientation and in many cases their gender expression. Does it actually mean that LGBTQ people are not getting treatment for their health problems in the mainstream health care sector? The answer is both, yes and no. While they are treated like any other heterosexual patient, the treatment is often without understanding the impact or role of a person’s sexual orientation and gender identity on his/her health.
A “Systems “ Problem
There exist several challenges in the mainstream healthcare systems that limit effective delivery of health to LGBTQ people.
First, there is a lack of or near absence of courses on sex, gender, sexuality and orientation in the medical education and training . This is a lacuna that runs from the top to lowest ranks of the health care providers. This lack of knowledge coupled with biases lead to unscientific healthcare approaches being resorted to by the healthcare providers.

Second, there is a huge legal barrier in the form of section 377, which prevents both patients and healthcare providers. Patients may not want to report certain health problems due to the fear of reprisal from the legal systems. Health care providers may also not want to deal with the patients whose behaviors are criminalized. This legal barrier coupled with social and religious beliefs may result into developing `homophobia’ `transphobia’ and `bi-phobia’. Patients also may not want to reveal their health problems due to internalized stigma pertaining to their sexual orientation.
Third, the range of health issues that needed to be addressed may tend to get lost in the broad, quick service or syndromic approach that have evolved due to the high patient volumes specially in the government hospitals. LGBTQ people may have a range of health needs, which a busy mainstream facility fails to cater to in an integrated manner . If there is too much workload in the OPDs, key questions such as sexual orientation, sexual and mental health may not be addressed by the healt care provider.
Fourth, there is a lack understanding of gender approach in the mainstream healthcare services. Gender as a concept may not be entirely understood by the healthcare providers. While sex is biologically assigned to a person based on the male or female genitalia at birth, gender is socially created roles, behaviors and patterns that a man or a woman is expected to display and live by. In that respect, both trans women and men find it difficult to share their health issues with healthcare providers. Also certain gender expressions like a man dressed in a saree (as in case of a trans woman) or a woman dressed in masculine clothes and having masculine mannerisms are often misunderstood and lead to discrimination in the health care set up. There is perpetually this question, `who will examine a person who is a trans woman? ’

Fifth, there is a lack of holistic approach on LGBTQ health . In the wake of HIV/AIDS prevention programs which were implemented by the national AIDS Control Organization through its district level agencies, major attention was given to the STI, HIV/AIDS related awareness, testing and linkages with the ART treatment. This largely covered men having sex with men (MSM) and transgender. However, women who were lesbians or bi-sexual and trans men did not come in the ambit of any kind of health care. Even in case of trans women, their needs have moved beyond HIV/AIDS. This group has a distinct need of guidance, counseling and healthcare pertaining to feminization and sex reassignment surgery. Then there are non-communicable diseases and mental health issues that need to be looked into holistically for the LGBTQ people keeping their sexual orientation in context.
Much Needed Change
In order to overcome the challenges mentioned above, there is a need to work at several levels. Mainly there is a need for the attitudinal shift towards LGBTQ people, which may take a very long time to happen. There is a need to recognize LGBTQ health as a key area for medical practitioners and include this scientific knowledge in the medical curriculum at all levels .
Presence of section 377 is a barrier, which is affecting lives of LGBTQ people in India. While there is legal battle being fought in the Supreme Court, the medical fraternity needs to recognize and accept health as a right that needs to be claimed by people irrespective of their sexual orientation to which they have an ethical obligation.
There is a need to impart extensive trainings on healthcare of LGBTQ to various rank and files of healthcare providers. Training programs should include doctors, nurses, technicians and allied staff to develop better understanding of LGBTQ health.
Long Term Viability
The vast scaling up required for LGBTQ healthcare cannot be driven by the NGOs alone . We need mainstream public and private hospitals to be the primary drivers and providers of healthcare.
The rights perspective makes it obligatory to any mainstream healthcare facility to treat a patient/ any patient. However, healthcare setups, especially private healthcare set-ups can be very selective in accepting certain kind of patients. Private healthcare setups should look at the large LGBTQ community who can afford healthcare in private set ups as potential clients and widen the base by providing holistic care.

While the government hospitals have selflessly provided affordable care and continue to do that, equipping them with the knowledge, resources and supporting them with NGO functionaries who act as a link or contact point between the hospital and community members can help change situation at the grassroots level.
Knowledge of health of Lesbian, Bi-sexual women and Trans men is relatively neglected. At country level both NGOs and the forums like federation for obstetric and gynecological society of India (FOGSI) need to come together to engage in dialogue and generate ideas to work on.
Finally, mainstreaming is the best and only option as it is the most democratic choice that would reach out to the LGBTQ community across India. This also has a room for market forces to operate thus benefitting both clients and private healthcare sector. However the key question is, does Indian healthcare have what it takes to mainstream LGBTQ healthcare needs in a non-stigmatized, service oriented and standardized manner?
Author :Alpana Dange
Alpana Dange is a founding partner of Partners in Progress, Mumbai. She is a trainer, researcher and strategic planner with over 20 years of experience in the social development field.
