Health Care Issues Faced by MSM & Hijras/Aravanis in India

1. HEALTH CARE ISSUES FACED BY MEN WHO HAVE SEX WITH MEN (MSM)& HIJRAS/ARAVANIS IN INDIA Dr. Venkatesan Chakrapani, M.D. cvenkatesan@hotmail.com Aug 2004

2. Objective of the presentation To summarize the main health care issues faced by MSM and Hijras/Aravanis in India Aug 2004

3. Expected outcome of the presentation • 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

4. 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

5. 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

6. 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) • Low self-esteem • Depression • Anxiety • Suicidal ideation (thinking) • Substance abuse (including alcohol and injecting drug use) Aug 2004

7. Over-view of health issues faced by MSM and Hijras/Aravanis in India (Contd.) c. Prejudice and discrimination in the medical settings: • 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

8. 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 or HIV status) Aug 2004

9. 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

10. Barriers to Health Care (Contd.) • 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

11. Barriers to Health Care (Contd.) • 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

12. 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

13. 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

14. 3. Allergy in anal area/penis • 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

15. 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

16. 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

17. 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

18. 5.Psychological/Mental (Contd.) • Sexual compulsive behavior • involvement in sexual activities that affect the normal day-to-day life • ? Sexual addiction • Medications prescribed sometimes. Aug 2004

19. 6. Indian Medical Professionals & Homosexuality • 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

20. 6. Indian Medical Professionals & Homosexuality (Contd.) • “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

21. 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

22. 7. ISSUES SPECIFIC TO HIJRAS/ARAVANIS • Non-availability of Hormonal therapy and Sex Reassignment Surgery in public hospitals • Self-administered hormonal therapy and its side- effects • Emasculation by quacks (unqualified medical practitioners) and its complications: post-operative infections, urethral stenosis/strictures (leading to urethralobstruction), 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 8. SEXUALLY TRANSMITTED DISEASES (STDs) Aug 2004

30. SEXUALLY TRANSMITTED DISEASES • 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). • These diseases can be transmitted by any kind of sexual practices – commonly - vaginal, or anal, or oral sex. • Some of these diseases caused by bacteria are curable (gonorrhea, syphilis, trichomonasis, chlamydia). • Others caused by viruses like Human Papilloma virus (HPV), Herpes, Hepatitis B, and HIV are not curable Aug 2004

31. WHY FOCUS ON STDs? • Some STDs cannot be cured (like herpes, HPV, or HIV) • Persons with STDs can be asymptomatic, and can spread STDs without even knowing they are infected. • Long-term complications: e.g., infertility, disorders of central nervous system (syphilis), tubal pregnancies that are fatal. • 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

32. Diseases Characterized by Genital Ulcers • Herpes • Chancroid • Syphilis • Granuloma Inguinale (GI) • Lymphogranuloma venereum (LGV) Aug 2004

33. 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

34. Diseases Characterized by Inguinal swelling • Chancroid • Lymphogranuloma venereum (LGV) Diseases Characterized by Swelling/growth • Warts (Anogenital) • Molluscum contagiosum (MC) Aug 2004

35. STDs and counseling • 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

36. 9. SAFER SEX Aug 2004

37. 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 Aug 2004

38. Dry kissing Wet (French) kissing Sensual touching Self-masturbation Mutual Masturbation Necking Caressing Hugging Frottage Breast caressing Breast sucking Erotic talk Using sex toys Sharing fantasies Telephone sex Cyber sex Bubble bath Water sports OTHER SEXUAL / EROTIC PRACTICES (Partial list) Aug 2004

39. Anal sex • Male condoms • Lubricants • ??Double condoms • Female condoms for anal sex? • Condom negotiation skills/Sexual communication skills Aug 2004

40. FEMALE CONDOM Aug 2004

41. Oral Sex (Fellatio) • HIV risk and oral sex • Oral sex and STDs • Condoms – flavored (strawberry, chocolate) • Swallowing semen Aug 2004

42. Rimming (Oro-anal sex) • STD and HIV risk • Dental Dam or Oral dam Aug 2004

43. Cunnilingus and Dental Dam Aug 2004

44. Fingering • Health risks • Finger gloves Aug 2004

45. 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 drug-resistant) • STDs can accelerate progression to AIDS Aug 2004

46. Hepatitis - A, B, C • 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

47. 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 (self-stigmatization) Discrimination ("enacted" stigma): • Unjustifiable negative behavior toward a group or its members. Aug 2004

48. 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

49. 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

50. 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