Transcript HealthIssues_MSM_Hijras_India

HEALTH CARE ISSUES FACED
BY MEN WHO HAVE SEX WITH
MEN (MSM)
& HIJRAS/ARAVANIS IN INDIA
Dr. Venkatesan Chakrapani, M.D.
[email protected]
Aug 2004
Objective of the presentation
To summarize the main health care
issues faced by MSM and
Hijras/Aravanis in India
Aug 2004
Expected outcome of the
presentation
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To have an overall idea about the various
health issues faced by MSM and
Hijras/Aravanis in India that will assist the
community activists to better advocate for
their health care issues.
Aug 2004
Outline of the presentation

Overview (list of the health issues)
 Barriers to health care
 Briefs on some health issues
 Issues specific to Hijras/Aravanis
 STDs
 Safer sex
 Stigma and discrimination in the medical
settings
Aug 2004
Over-view of health issues faced by
MSM and Hijras/Aravanis in India:
a. Sexual health/HIV/AIDS
- Sexually Transmitted Diseases (STD)
- HIV/AIDS (medical issues, disclosure to
families/partners, etc.)
- Misconceptions about sexual health (that
affect health-seeking behavior)
- Trauma (anal/foreskin tear)
- Allergy – anogenital area
- Sexual dysfunction and Marital problems
Aug 2004
Over-view of health issues faced by MSM
and Hijras/Aravanis in India: (Contd.)
b. Psychological/Mental health: (Most are
secondary to society’s prejudice/discrimination)
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Low self-esteem
Depression
Anxiety
Suicidal ideation (thinking)
Substance abuse (including alcohol and
injecting drug use)
Aug 2004
Over-view of health issues faced by
MSM and Hijras/Aravanis in India (Contd.)
c. Prejudice and discrimination in the
medical settings:
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Health care provider bias
(assumption about sexuality, pathologizing
same-sex behavior, trying ‘conversion
therapy’, etc.)
 Harassment and discrimination
(verbal abuse, physical violence, sexual
violence)
Aug 2004
Over-view of health issues faced by
MSM and Hijras/Aravanis in India (Contd.)
d. Self-stigma and Concealing sexual
behavior/identity:
 Reluctance or delay in seeking preventive or
curative care (e.g., for STDs)
 Incomplete medical history (consequently
increased health risks)
e. Chronic health issues:
 Hepatitis (HBV, HCV, HAV – due to sexual
behavior or injecting drug use)
 Anal cancer (due to specific types of warts
Aug 2004
or HIV status)
Barriers to Health Care
Men who have sex with men (MSM) and
transsexuals face unique barriers when accessing
public or private care offered by health care
providers in India.
Some of these include:
 fear of bias or prejudice from the health care
provider (HCP)
 past negative experiences from HCP because
revealed same-sex behavior.
 Homophobia/biphobia/transphobia from HCP
Aug 2004
Barriers to Health Care (Contd.)
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Refusal to treat or providing substandard care of
persons who revealed their same-sex behavior to HCP
HCP trying to ‘cure’ same-sex attracted persons from
‘homosexuality’
Pathologizing of same-sex/bisexual orientation by
HCP
Low self-esteem among the GLBT patients
Heterosexual assumptions on medical forms and in
providing medical information on sexual and
reproductive health
Gender assumptions on medical forms and not
thinking about persons who could be
transgender/transsexuals.
Aug 2004
Barriers to Health Care (Contd.)
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Concerns about breach of confidentiality
Fear of being ‘outed’ to others
MSM and Hijras stigmatized as ‘risk-groups’ and
for spreading HIV infection in to the ‘general
population’.
Refusal to treat or don’t know how to treat
transgender persons who request hormone therapy
or sex change operation.
Exclusion from health promotion campaigns
including STD/HIV public awareness programs
Aug 2004
1. Misconceptions about
sexual health/HIV
- Semen loss (blood / semen) and weakness
- Pouring lime juice over penis can prevent
HIV/STDs.
- Washing anus with seawater (after anal sex)
can prevent acquiring HIV.
- HIV cure – by drinking urine
- Anal ulcers can be cured by having
unprotected anal sex
Aug 2004
2. Trauma (anal/foreskin tear)
Anal trauma
- forced (first time) anal sex
- Larger/disproportionate size penis
- Introducing (‘sharp’) objects – carrot, bottle, etc.
- Lower intestine tear (abdominal infection)
Trauma to foreskin (prepuce)
- due to vigorous sex in those who have phimosis
(tight and unretractable foreskin)
Aug 2004
3. Allergy in anal area/penis
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Due to lubricants in condom or lubricants
used in sex
 Latex allergy (latex condoms)
[One can use polyurethrane condoms]
 Some drug allergies – manifest in genitalia
Aug 2004
4. Sexual dysfunction and
Marital problems
Erection problem/No sexual desire
- with female spouse (if same-sex orientation)
- with male steady partner (if relationship problem)
Relationship problems with female spouse
- can be an erection problem
- Not ‘taking care’ of female spouse
- Domestic violence
Aug 2004
5.Psychological/Mental
(Note:Most are secondary to society’s
prejudice/discrimination)
Depression/Anxiety/Suicidal ideation:
- Many reasons
E.g.; internalized homophobia,
nonacceptance by the family, secondary to
failed relationships (male/female), marital
problems
- Lack of self-worthiness, low self-esteem
Aug 2004
5.Psychological/Mental (Contd.)
Self-destructive behavior
a. Substance abuse (including alcohol
and injecting drug use)
- Lack of self-esteem/nonacceptance of
sxl orientation/gender identity by others
b. Taking risks: Multiple sex partners to
affirm gender identity
(transsexuals/Hijras)
Aug 2004
5.Psychological/Mental (Contd.)
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Sexual compulsive behavior
involvement in sexual activities that affect
the normal day-to-day life
? Sexual addiction
Medications prescribed sometimes.
Aug 2004
6. Indian Medical Professionals &
Homosexuality
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Indian psychiatrists either follow ICD-10
(WHO) or DSM-IV (APA). These standard
manuals say that homosexuality per se [as
such] should not be considered as a psychiatric
disorder. However some psychiatrists still try
‘conversion therapies’ or ‘reparative
therapies’.
Many doctors may not be aware that like
laypersons they too may be sexist,
heterosexist, misogynist, and ‘homophobic’.
Aug 2004
6. Indian Medical Professionals &
Homosexuality (Contd.)
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“Moral virus infection” of the medical
community – is one of the key reasons
behind discrimination of sexual
minorities.
Sexual morality among health care
providers should not lead to denial of or
provision of suboptimal care to sexual
minorities.
Aug 2004
Homosexuality and
International Classification of Diseases (ICD-10)
F66 Psychological and behavioural disorders
associated with sexual development and
orientation
F66.0 Sexual maturation disorder
F66.1 Egodystonic sexual orientation
F66.2 Sexual relationship disorder
F66.8 Other psychosexual development disorders
F66.9 Psychosexual development disorder,
unspecified
A fifth character may be used to indicate association with:
.x0 Heterosexuality .x1 Homosexuality .x2 Bisexuality
.x8 Other, including prepubertal
Aug 2004
7. ISSUES SPECIFIC TO HIJRAS/ARAVANIS
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Non-availability of Hormonal therapy and Sex
Reassignment Surgery in public hospitals
Self-administered hormonal therapy and its sideeffects
Emasculation by quacks (unqualified medical
practitioners) and its complications: post-operative
infections, urethral stenosis/strictures (leading to
urethral obstruction), urinary fistulas
Chronic obstructive uropathy leading to kidney
failure (may be due to urethral stenosis and/or
chronic prostatic enlargement. Note: Prostate gland
is not removed in emasculation)
Aug 2004
7. ISSUES SPECIFIC TO HIJRAS/ARAVANIS
a. Discrimination faced by Aravanis/Hijras
 using male pronouns in addressing them
 enrolling them as ‘males’ and admitting in
male wards (Chennai)
 abuse by the hospital staff and co-patients
(see the article handout)
Aug 2004
7. ISSUES SPECIFIC TO HIJRAS/ARAVANIS
b. The Tenth Revision of the International Statistical
Classification of Diseases and Related Health Problems
(ICD-10)
F60F69
Disorders of adult personality and behaviour
 F64 Gender identity disorders
 F64.0 Transsexualism
 F64.1 Dualrole transvestism
 F64.2 Gender identity disorder of childhood
 F64.8 Other gender identity disorders
 F64.9 Gender identity disorder, unspecified
Aug 2004
7. ISSUES SPECIFIC TO HIJRAS/ARAVANIS
c. Guidelines for Sex Reassignment Surgery (SRS)
 Harry Benjamin International Gender Dysphoria
Association (HBIGDA) Guidelines & DSM-IV
 ‘Diagnosis’ and Counseling by psychiatrists/clinical
psychologists
 The patient must first undergo the Real Life Test
(RLT)
 The patient lives and works as the “new” gender for
a year in order to learn how to survive
 The patient also begins to take hormones to alter
body chemistry
Aug 2004
7. ISSUES SPECIFIC TO HIJRAS/ARAVANIS
For Male to Female Transsexuals (MTFT)
 vaginoplasty (construction of a vagina)
 penectomy (removal of the penis)
 orchidectomy (removal of the testes)
 clitoroplasty (construction of a clitoris)
 breast augmentation (breast enlargement)
 rhinoplasty (reshaping the nose)
 hair transplants and face remodeling
Aug 2004
7. ISSUES SPECIFIC TO HIJRAS/ARAVANIS
(‘Female’) Hormonal Treatment
 Hormones are manufactured and controlled by the
endocrine system
 They are chemical messengers to the body
 “Artificial” hormones may be given to patients to
produce desired effects
 Sometime there are also some undesired effects.
 Hormones may have different effects for different
patients
 “Feminizing hormones” – estrogen/progesterone
Aug 2004
7. ISSUES SPECIFIC TO HIJRAS/ARAVANIS
d. Methods followed by Aravanis
 Hair removal – using ‘Chimta’
 Breast development – using oral
contraceptive pills
 Emasculation operation – by quack doctors
or qualified doctors. Until recently, by
ThaiAmma or self.
 Rarely undergo vaginoplasty (since costly)
Aug 2004
8. SEXUALLY TRANSMITTED
DISEASES (STDs)
Aug 2004
SEXUALLY TRANSMITTED DISEASES
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A disease is called sexually transmitted or venereal
if that disease can be transmitted by any sexual
practices (the microbe may be present in the semen,
or anal or vaginal secretions).
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These diseases can be transmitted by any kind of
sexual practices – commonly - vaginal, or anal, or
oral sex.
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Some of these diseases caused by bacteria are
curable (gonorrhea, syphilis, trichomonasis,
chlamydia).
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Others caused by viruses like Human Papilloma
virus (HPV), Herpes, Hepatitis B, and HIV are not
curable
Aug 2004
WHY FOCUS ON STDs?
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Some STDs cannot be cured (like herpes, HPV, or
HIV)
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Persons with STDs can be asymptomatic, and
can spread STDs without even knowing they are
infected.
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Long-term complications: e.g., infertility,
disorders of central nervous system (syphilis),
tubal pregnancies that are fatal.
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Presence of STDs makes transmission of HIV 3 to
5 times more likely. Thus controlling STDs is a
cost effective way of preventing HIV infection.
Aug 2004
Diseases Characterized by
Genital Ulcers
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Herpes
 Chancroid
 Syphilis
 Granuloma Inguinale (GI)
 Lymphogranuloma venereum (LGV)
Aug 2004
Diseases Characterized by
Anogenital Discharge
Urethral/Vaginal/Rectal discharge
 Gonorrhea
 Chlamydia
Vaginal discharge (inaddition to the above two):
 Bacterial Vaginosis (BV)
 Trichomoniasis (TV)
 Vulvovaginal Candidasis (VVC)
Aug 2004
Diseases Characterized by Inguinal
swelling
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Chancroid
 Lymphogranuloma venereum (LGV)
Diseases Characterized by
Swelling/growth
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Warts (Anogenital)
 Molluscum contagiosum (MC)
Aug 2004
STDs and counseling
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Partner screening and treatment (male and
female partners)
 No unprotected sex during treatment period
 Simultaneous treatment for partners
 Recurrence (herpes and warts)
 Transmission during asymptomatic phase
(herpes, warts)
Aug 2004
9. SAFER SEX
Aug 2004
Penetrative sexual practices
Anal sex – insertive, receptive
 Oral sex – Fellatio (Peno-oral sex)
 Anilingus (oro-anal sex)
 Cunnilingus (oro-vaginal)
 Fingering – introducing finger into rectum or
vagina
 Fisting – introduction of fist into rectum or
vagina
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Aug 2004
OTHER SEXUAL / EROTIC
PRACTICES (Partial list)
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Dry kissing
Wet (French) kissing
Sensual touching
Self-masturbation
Mutual
Masturbation
Necking
Caressing
Hugging
Frottage
Aug 2004
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Breast caressing
Breast sucking
Erotic talk
Using sex toys
Sharing fantasies
Telephone sex
Cyber sex
Bubble bath
Water sports
Anal sex
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Male condoms
 Lubricants
 ??Double condoms
 Female condoms for anal sex?
 Condom negotiation skills/Sexual
communication skills
Aug 2004
FEMALE CONDOM
Aug 2004
Oral Sex (Fellatio)
 HIV risk
and oral sex
 Oral sex and STDs
 Condoms – flavored (strawberry,
chocolate)
 Swallowing semen
Aug 2004
Rimming (Oro-anal sex)
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STD and HIV risk
 Dental Dam or Oral dam
Aug 2004
Cunnilingus and Dental
Dam
Aug 2004
Fingering
 Health
risks
 Finger gloves
Aug 2004
SAFER SEX FOR HIV-POSITIVE
PERSONS
By explaining - How safer sex practices of
HIV-infected persons help them?
– prevention of acquiring new STDs
– prevention of superinfections with other
HIV type/strains (virulent and drugresistant)
– STDs can accelerate progression to AIDS
Aug 2004
Hepatitis - A, B, C
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Hepatitis A
– transmission by fecal-oral route/rimming
(oro-anal sex)
– vaccine preventable
 Hepatitis B
– Injecting drug use/blood/Sexual transmission
– vaccine preventable
 Hepatitis C
– Spread thorough mainly injecting drug use/blood
– Sexual transmission plays limited role
Aug 2004
9. FIGHTING AGAINST STIGMA &
DISCRIMINATION IN THE MEDICAL
SETTINGS
Definitions
Stigma:
 A quality that ‘significantly discredits’ an
individual in the eyes of others.
 Experience of others’ negative attitudes (selfstigmatization)
Discrimination ("enacted" stigma):
 Unjustifiable negative behavior toward a group or
its members.
Aug 2004
9. FIGHTING AGAINST STIGMA &
DISCRIMINATION IN THE MEDICAL
SETTINGS (Contd.)
Overt discrimination
Discrimination by ‘act of commission’ (“by
doing”)
 Denial of care once sexual behavior or
orientation is known.
 Provision of suboptimal care after knowing
the sexual behavior/orientation or gender
identity/expression.
 Abuses/Violence – verbal, physical or sexual
Aug 2004
9. FIGHTING AGAINST STIGMA &
DISCRIMINATION IN THE MEDICAL
SETTINGS (Contd.)
Covert/Hidden Discrimination
 This is mainly discrimination by “not doing”.
 Examples:
- not asking about same-sex/bisexual behavior
when taking sexual history
- not involving same-sex steady partners in
treatment decision-making
Aug 2004
Possible ways to reduce
stigma and discrimination
There is a need for a comprehensive strategy to
combat stigma and discrimination against
sexual minorities in the Indian health care
system.
 Ongoing documentation of stigma and
discrimination against sexual minorities in
the health care system:
- to know about the various forms in which
discrimination occurs
- to design appropriate strategies to prevent
the same.
Aug 2004
Possible ways to reduce
stigma & discrimination (Contd.)
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Conducting sensitization programs for all
health care providers and health management
persons at various levels. (govt., and private)
 Conducting intensive training programs for
health care providers where clinical or
counseling care of sexual minorities differ from
the ‘general population’ (example: STD
physicians, Urologists, HIV counselors) (govt.,
and private) [CME, Ad hoc training programs]
Aug 2004
Possible ways to reduce
stigma & discrimination (Contd.)
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Integration of information about the health
issues of sexual minorities through out the
medical, paramedical, nursing and counselors’
curriculum. (in government and private
universities)
 Health care management level (govt. and
private) – Non-discriminatory policies at the
institutional level, more inclusive ‘intake’ forms
(marital status, gender)
 Professional organizations: Position statements
and code of conduct Aug
for2004physicians
Possible ways to reduce
stigma & discrimination (Contd.)
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Need for a national health strategy (especially
sexual health/HIV) for sexual minorities that
also addresses stigma and discrimination
 Need for a public health policy to perform sex
reassignment surgery and provision of
hormonal therapy to transsexuals in the public
health system.
 Research on designing appropriate
interventions to reduce stigma and
discrimination in the health care system
Aug 2004
Possible ways to reduce
stigma & discrimination (Contd.)
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Addressing discrimination against the
sexual minorities under the broad
category of stigma and discrimination
faced by marginalized groups (female sex
workers, injecting-drug users, and people
living with HIV/AIDS) in the Indian
health care system.
Aug 2004
What the community groups
can do?
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Understanding how changes can be brought about
in the health care system and then devising
appropriate strategies.
 Ongoing documentation of stigma and
discrimination and using that information as an
advocacy tool. Documentation of best practices and
innovative strategies in decreasing stigma and
discrimination.
 Advocating with the local health management
team of hospitals – to organize sensitization/
training programs and to have non-discriminatory
policies.
Aug 2004
What the community groups
can do?
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Advocating with the state Directorate of
Medical Education and Medical University
management to include the health issues of
sexual minorities in the medical curriculum.
 Advocate with local branches of professional
organizations to conduct sensitization
programs for health care providers in their
constituencies.
 Educating the health care providers in one-toone encounters in an appropriate manner.
Aug 2004
What the community groups
can do?
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Can organize the sensitization programs for
health care providers by themselves or with
the help of community-friendly agencies or
health care providers.
 Advocating for the formulation of a national
health strategy (especially sexual health/HIV)
for the sexual minorities – in consultation with
the community groups.
 Building alliances with other marginalized
groups (sex workers, IDUs, PLHA) that also
experience discrimination in the health care
system.
Aug 2004