The invisible ones: sexual minorities.

Sexual minorities are a group whose sexual identity, orientation or practices differ from the majority of the surrounding society. Usually, Sexual minorities comprise of lesbian, gay, bisexual and transgender individuals1. Male-female dichotomy in hetero-normative societies has created havoc in the life of sexual minorities thus obscuring the fact that they are also human beings. The intent here is to bring to light the violation of basic human rights of this community and need for provision of equal opportunities and protection of rights like any other law abiding citizen.

The disparity in health care for the sexual minorities exists in all societies. For example, transgenders do not have a separate ward in any hospital or any beds reserved for them. Often they are not even allowed inside hospitals and do not have separate ward earmarked for in-patient care. Their access to health care needs to be ensured because they are at a high-risk for various physical and mental illnesses2. Here we focus on health issues of sexual minorities with respect to definition of ‘health’ by World Health Organization - physical, mental and social well-being documented in the preamble to the constitution of World Health Organization (1946).

Physical health: Sexual minorities are at high risk for developing sexually transmitted diseases (STDs) and HIV/AIDS3. The reason for high prevalence of HIV is attributed to re-use of needles and unprotected intercourse as part of commercial sex work both in hetro- and homo-sexual relationship4. They are also high-risk victims of physical, sexual, economical and emotional violence from the so called normal community5.

Many transgender would like to undergo hormonal therapy and sex reassignment surgery (SRS). Unfortunately they are denied these services in majority of hospitals. Many of the surgeries are done without proper assessment, psychiatrist opinion, hormonal therapy and real life experience or even adequate aseptic precautions. Most of the individuals undergoing surgery and also the professionals performing are unaware of the Harry Benjamin Standard of care for SRS6. There is an urgent need to standardize SRS guidelines for Indian transgender community and also there is a need to make whole process of sex reassignment surgery services available, affordable and accessible in public and private hospitals.

Mental health: Sexual minorities are at a risk for developing emotional disorders because of the stigma and discrimination7. Suicide risk has been shown to be greatly elevated for men in same-sex partnerships in Denmark8. Transgenders were forced out of their homes or chose to leave home because of parental rejection or fear of rejection, increasing their risk of homelessness, poverty, and associated negative sequelae9. They are physically, verbally, and sexually abused5, which gets manifested as depression, panic attacks, suicidal ideation, psychological distress, body image disturbance and eating disorders10. Sexual minority adolescents leave home more frequently in search of their identity, and are victimized and forced for sex more often11. They use highly addictive substances more frequently to overcome their sorrows12 and have more sexual partners than their heterosexual counterparts13. Heavy alcohol drinking and use of drugs remain a significant public health problem in this population14. High level of discrimination may underlie the observations of greater psychiatric morbidity risk among sexual minorities15.

Social well-being: Extreme social exclusion, discrimination, stigma and atrocities diminish self-esteem and sense of social responsibility5. Sexual minorities recognize that they are different from the ‘majority others’, during their adolescence. Many of them end up in marital/heterosexual relationships against their will because of family and societal pressure. These marriages end up in marital disharmony, divorce or continue with poor quality of life. Legal inheritance is often denied by their family members. They are not allowed inside the premises of the educational institutions. Hence, illiteracy is very common among the sexual minority. They are not considered for government jobs. Even if they have a job, they are suspended from the job once their gender identity/sexual orientation is revealed. They are not allowed inside hotels, hospitals, cinema halls, and government offices as indeed in most public spaces. Discrimination and non-friendly environment at work place force them to take up begging and prostitution for their livelihood.

Sexual minorities find it difficult to get a house on rent, and frequently change their residence. Thus it is difficult for them to produce proof of residence. Subsequently, many of them do not get social or disability pension, voters ID, ration card, passport and many of them do not even get a caste certificate. There have been multiple instances in which they had to approach the court for getting medical certificates. They also get excluded in the population census. Hence, they are a non-existent or an invisible community, who do not get included in any social and health policy.

Sex work by sexual minorities invites exploitation by both, clients and the police. There has been a landmark judgement by Delhi High Court in Naz Foundation vs. Union of India case, on July 2, 200916 that has upheld their rights. High Court of Delhi recognized the anachronism associated with Section 377 IPC and interpreted it to exclude sexual acts between consenting adults, thus decriminalizing homosexuality. This judgement may be regarded as one of the stepping stones to uphold the rights of the sexual minorities.

Media has also played a negative role in depicting them as violent and criminal. There are only a few non-governmental agencies in India such as Sangama, Samara, Naz foundation and PUCL (People's Union for Civil Liberties) fighting for their rights. There is an urgent need to address this issue to uphold the fundamental rights guaranteed under constitution of India.

In conclusion, sexual minorities experience health care disparities that will be eliminated only if clinicians elicit information about sexual orientation and gender identity from their patients through thoughtful, non-judgemental discussion and history-taking10. A recent systematic review identified consistent recommendations across studies at primary care settings to have an inclusive clinical environment, standards for clinician-patient communication, sensitive documentation of sexual orientation, knowledge for cultural awareness, staff training, and addressing population health issues17. To overcome homophobia, there is an urgent need to invest on research in this area and inclusion of issues on sexual minority in the medical curriculum. This may help health professionals to improve their response to health disparities and also become sensitive to the needs of this population.