How An Arts Campaign Seeks To Bring Gender Sensitivity To Healthcare
A creative initiative using literature and visual arts hopes to educate and sensitise medical students and practitioners about gender-affirmative care
The medical student passing by my room/ suddenly stops and lecherously peers inside.
Binded in a cuff of inflating air, I avoid his lustful/eyes and stare at the walls, painted in blinding white.
The nurses whisper and giggle together/my presence here is their exciting secret tonight.
The hospital-mandated robe offers no protection/the icy fingers of the AC piercing my fibers of thin white.
Why this fear of people and place whose/ only purpose is to aid, to cure, to heal, Abhi?
What can I say except my rainbow-drenched body/is forbidden from sipping their grail of pure white?
These lines are from White, A Ghazal written by Sam, 22, a non-binary and transmasculine person based in Bengaluru. Sam, who celebrates their identity, gender and sexuality through their writing, articulates in this ghazal their traumatic experience of the Indian healthcare system.
“I chose the ghazal form as I felt it helped carry heavy images in a more poetic, visually appealing way. I was inspired by [Indian American poet] Agha Shahid Ali, who paved the way for the practice of English ghazal writing in India,” says Sam.
The complexities of living in a society that is more accepting of binaries become even more pronounced when it comes to accessing healthcare. Biases, ignorance and a skewed medical education system become roadblocks in the LGBTQIA+ community’s pursuit of understanding, acceptance and affirmative care, as Behanbox has reported extensively (here, here and here).
“Many people regard me as an object to be scrutinised, and when I go to hospitals, I find that the nursing staff, doctors, and receptionists are extremely rude. They don’t take my queries seriously, and in the forms that I fill, I have no option of letting them know the pronouns I prefer,” says Sam. “I dress in a stereotypical masc fashion; I have short hair and multiple piercings. But often I don’t feel safe enough to share that I identify as a transmasculine person.”
Sam’s ghazal is part of Queer Chronicles (QC), an initiative launched by Sangath, an NGO-based in Bhopal, which aims to use an arts-based approach to educate, inform and sensitise medical students and practitioners on the unique medical needs of the LGBTQIA+ community.
The initiative is creating a pool of first-person narratives – poems, stories, zines and short videos – on the experiences of people from the LGBTQIA+ community within India’s healthcare system and settings. Early this month the initiative began posting this content on its social media handles. By the end of October 2024, the content will also be made available in an open access virtual museum and it will be used to train healthcare professionals in medical colleges as well as hospitals.
“Queer Chronicles started when we were working on another project looking at the needs of the LGBTQIA+ community. We realised that there is a need for doctors and other healthcare professionals to be sensitised,” says Joshua Mark George, project coordinator, Sangath. “We need to make changes in medical education, and train faculty in medical colleges to be queer and disability inclusive. We need stories that would have a connect with medical students and healthcare professionals or anyone who wants to use it in their colleges.”
Sangath’s team members include medical educators at University College of Medical Sciences (UCMS), and Jamia Hamdard University, and they will be piloting the initiative in their institutions. Sangath is also putting together a teaching guide for educators on the questions and themes they can raise in classrooms.
‘Not Taken Seriously’
Despite multiple government measures, transmen and transmasculine persons face several barriers to health care, as Behanbox has reported referring to the 2023 study ‘Our Health Matters’.
“Cis-gender people are taken more seriously and get diagnosis and treatment sooner. Apart from homophobia and transphobia, people also make offhand comments. There is a lot of gaslighting and dismissal where the health concerns of queer people are concerned,” says Joshua of Sangath. He adds that healthcare issues get even more problematic for queer people at the intersection of queerness, disability, caste and mental health, as Behanbox had earlier reported.
Only 46% of the 377 trans men interviewed from 22 union territories and states had access to a doctor for their general health concerns, according to the 2023 study conducted by the Transgender Welfare Equity and Empowerment Trust (TWEET) Foundation, the Transmen Collective, the Drexel University and the Population Council.
Up to 33% of respondents avoided healthcare for fear of being mistreated, and 80% of those who had surgery paid for it themselves or took the help of friends and family. Transgender persons in India have been included in public welfare schemes such as the Support for Marginalized Individuals for Livelihood and Enterprise (SMILE) Scheme that provides them educational and skilling opportunities, health, housing services and the Ayushman Bharat scheme that offers health insurance benefits. But social attitudes and bureaucratic hurdles make it hard for them to access these benefits, said the study.
One of the major recommendations of the study as well as the Transgender Persons (Protection of Rights) Act is to create gender-affirmative healthcare guidelines in alignment with the 8th edition of the World Professional Association for Transgender Health Standards of Care (WPATH). These standards provide clinical guidance to healthcare professionals on how to help transgender and non-binary persons access safe, preventive and transition related and gender-affirmative care.
‘They Treat Us Like Abnormal People’
Interactions with healthcare professionals can heighten the feeling of alienation among the queer people, we found.
Shantanu, who was on hormone replacement therapy and underwent a mastectomy, dreads visits to gynaecologists. “I have not had a hysterectomy yet as my doctor asked me to wait. Gynaecologists are not comfortable doing a pelvic exam for a bearded ‘man’. Even after I explain that I am a trans man who has retained my female reproductive organs, they don’t understand and treat me like I am abnormal,” he says.
There is a lack of understanding of gender identity and sexual orientation among healthcare professionals, says L Ramakrishnan, vice president of the public health NGO SAATHII that works to increase inclusive access to rights. The organisation has been collecting and documenting case studies of people of the LGBTQIA+ community who have faced unscientific and unethical treatment in the healthcare system in 10 states. These are documented internally, and some cases are published on an online portal, keeping names and locations confidential.
“At a transgender clinic in Tamil Nadu, the two-finger test (which has been banned for Cis women) is done for trans men even when they seek a psychiatrist’s letter for medical and surgical interventions. And if it shows that they have had sex with a person with a penis, they are deemed not to be a transman. We have approached the National Health Mission regarding this,” says Ramakrishnan.
In the current landscape, queer individuals often encounter the medical system in only specific contexts, such as seeking treatment for HIV, mental health support, or undergoing gender affirming surgery, said Aqsa Shaikh, one of India’s first transgender doctors and an associate professor of community health, in an interview with Behanbox.
“Medical students and doctors perceive queer individuals solely through the lens of these medical interventions, in terms of bodies and minds that need ‘change’. This also limits their understanding of the diverse experiences and needs within the queer community,” she said.
Need To Start Early
Community members, activists, NGOs, and healthcare professionals have spoken about the need to address the issue at its roots – by bringing much-needed changes to the medical curriculum.
“In many medical textbooks, homosexuality and bisexuality are reported as disorders though, in 1990, WHO removed homosexuality from being categorised as a disorder,” says Ramakrishnan. “Psychiatry textbooks, even today, use the term gender identity disorder to describe trans persons, though WHO has removed the categorisation. The new term is gender incongruence, but changes need to be made to the curriculum and find their way into the textbooks.”
Research has revealed that most of the training material is not based on the lived experiences of the LGBTQIA+ population with the Indian healthcare system. Also these experiences are introduced to healthcare professionals late in life.
“When students enter medical colleges at the age of 18, their thoughts, beliefs, values, biases, misconceptions, etc are quite fixed,” Shaikh told Behanbox in her interview. The expert, who was also involved in Sangath’s TransCare Med-Ed project to find ways to create trans affirmative curriculum, pointed to the fact it was not till the 21st century that queer people stopped being categorised as criminals or mentally ill people. It is only recently that the healthcare system and medical education slowly started moving from pathologising queer folks to a stage where it is agreed that it is no longer a disease or a crime to be queer.
There is now more administrative commitment as well as a willingness among medical educators to change the curriculum and among practitioners to go beyond treating queer people as “exotic” beings with medically inexplicable biological or psychological variations, she added.
According to Shaikh, the current gap in healthcare systems is that queer individuals often encounter the medical system only in specific contexts – seeking treatment for HIV, mental health support, or undergoing gender affirming surgery. But how does the queer body respond to illnesses such as anemia or how a doctor should deal with an abdominal surgery in a trans woman – these are questions that should now be studied, she said.
Getting Creative
It was to address the lacunae in medical education, Queer Chronicles launched last July. “We wanted to train people from the community to articulate their stories effectively through art – painting, comics, zines, documentaries, dance,” says Joshua. “We noticed that people connect more genuinely with a story, video or poem. It generates more sympathy and sensitivity among students.”
The first workshop was held in October 2023. “We flew down people from the LGBTQIA+ community from across India. In the second workshop, held in February 2024, we focussed on getting participants from the northeast and south India to ensure more representation. The third workshop had people from the community in Bhopal,” says Joshua. “The only criteria for selection were that they should be interested in sharing their stories and experiences while dealing with the healthcare system.”
For some, expressing themselves creatively has been cathartic. Tripura-based Aindriya Barua says they have always been writing about things that have happened in their lives.
“When I heard about the Sangath initiative, I wanted to participate as writing has been a way for me to express myself, and find closure,” says the 27-year-old, who identifies as a non-binary person. For Queer Chronicles, Aindriya has written an essay, ‘Breaking Up With My Therapist’, on their experiences with mental health professionals.
“Four years ago, I sought therapy as I was trying to understand asexuality. I told the therapist that I don’t feel like having sex with any man and she just said it’s a good thing and I should preserve myself for marriage. There was no attempt to understand me, or what I was seeking help for,” they say.
Many members of the community battle mental health issues. According to the ‘Our Health Matters’ study we referred to earlier, about one-third of the transmasculine people interviewed had moderate or severe depression, while 45% had moderate or severe anxiety. Almost half (44%) had ever seriously considered suicide, while over a third had attempted it.
In dealing with mental health challenges it is important to have a community network to lean on, said Gautam Ramchandra, co-chair of TWEET Foundation at a discussion following the release of the report. Access to mental health remains fraught for queer and trans people across India, especially from small-town India, as Behanbox reported earlier. Queer women in India face their own set of challenges, dealing with disbelief, lack of acceptance, social isolation and prejudice that can escalate to coercion and violence by society.
Teaching Through Stories
So far, 19 stories have emerged from Sangath’s workshops. “They are in different formats — we have audio-visual narratives, zines, a ghazal, essay and poems,” says Joshua, adding that they will be posting the content on Sangath’s social media handles and also upload it to their website and another one specially created for the initiative. “We will make a teaching guide that will be available in print and online by the end of September. It will be widely disseminated so that medical educators can use it more freely to bring in sensitivity. Some stories are already being used in existing material.”
Other organisations have also been working to bring about a change in the healthcare system and make it more inclusive.
SAATHII has done training programmes for Madras Medical College, Chennai, Regional Institute of Medical Sciences, Imphal; Kozhikode Medical College, Kerala; University College of Medical Sciences, Delhi; Post Graduate Institute of Medical Education and Research, Bhubaneswar, and numerous state chapters of professional medical associations over the past 15 years.
“In 2018, we developed a course on transgender health for Kasturba Gandhi Nursing College Puducherry,” says Ramakrishnan. “In every discipline, such as physiology, endocrinology, or, while teaching post operative care, there are specific concerns where trans people are concerned.”
SAATHII has also drafted a paediatrics curriculum to ensure affirmative care for children who are gender nonconforming, intersex or of a non-normative sexual orientation.
“In most textbooks, they only talk about adolescence in the Cis binary sense; both in terms of the child’s gender identity, and attraction to the opposite gender. People are uncomfortable talking about topics such as gender dysphoria, but it needs to go into paediatric curriculum. We have worked with a paediatric resident at Boston Children’s Hospital to develop the course,” says Ramakrishnan. “The National Medical Commission (NMC) has also modified modules for psychiatry and forensic medicine taught to undergraduate medical students to make it more inclusive.”
The danger that these hardwon gains can also be undone became clear this month when the NMC attempted to revise the medical curriculum by bringing back bringing back definitions of virginity and “defloration”, removing the distinctions between consensual sex between queer individuals.
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