Abstract

In spite of the Supreme Court’s recognition of transgender and LGBTQIA+ rights, there has been a negligent and insensitive attitude in India to the question of rendering respect to individuals of all sexual and gender identities. No framework for ensuring better protection from societal discrimination faced by the LGBTQIA+ community has been drawn up; hence discrimination continues in society and in healthcare. This article aims to provide an understanding of the terms frequently encountered with the LGBTQIA+ population and orient healthcare professionals to be better equipped at using the correct terms in their everyday practice, as a step towards a more inclusive healthcare system.

Keywords: SOGIESC, transgender rights, misgendering, sexual orientation, appropriate terminology

Introduction

Ten percent of the Indian population consists of the LGBTQIA+ community [1] who express themselves according to their own sexual orientation, gender identity and expression, and sexual characteristics (SOGIESC). Among them, legal recognition was only given to the “third gender” after the landmark decision of the Supreme Court of India (SC) in April 2014 [2]. With the recognition of the third gender should flow the fundamental human rights including the right to unbiased medical care [3] which falls within the legal and constitutional protection applicable to transgender people. Another landmark judgment decriminalised consensual homosexual sex between adults [4]. Despite these advances, healthcare for transgender people and the entire LGBTQIA+ community in India is plagued with shame and discrimination. Most doctors lack a general awareness on gender identity and sexual orientation [5], due to certain stereotypes based on bad encounters in society or negative portrayal in mainstream media [6]. This has led to repeated, harmful cases of misgendering of people [7, 8] along with wrongful assumptions on their sexual orientation stemming from the rigid ideological biases that exist on SOGIESC. One such study conducted by A Kar et al found that 15.9% of medical students believed that homosexuality was an illness [9] in spite of the Indian Psychiatric Association and other articles contradicting this [10, 11]. In addition, 24.8% of those studied considered homosexuals neurotic and 8.2% thought that they posed a danger to children [9].

The lack of scientific orientation in the Indian medical profession may account for the deficit in acceptance and the high prevalence of discrimination based on SOGIESC [12]. It is hoped that this paper, by promoting awareness of appropriate terminology, will encourage healthcare providers and community members to sensitively use someone’s appropriate gender pronouns and sexual orientation. Such a practice will not only reinforce the patients’ trust in the physicians but could also help patients communicate better by creating a space where they feel safe enough to talk about their problems openly.

Consequences of misgendering

Language is performative in that, in this case, there is a force of insult contained in the repetition of the current exclusive “norm”. Heteronormativity is recognised as the ideal, and is linked with a history of exclusion [13]. This results in reiterated shaming. To correct this, therefore, the onus is on healthcare professionals to ensure they incorporate an inclusive and healthy healthcare environment.

Children should be afforded autonomy with respect to their SOGIESC, irrespective of their age. Negative emotions when witnessed by growing children tend to breed strong and hateful emotions as they grow up. This extends to exercising their power of autonomy with regard to their sexual and reproductive health. If not properly educated, they end up dysphoric to their own SOGIESC [14].

While there might be rising awareness about gender diversities and sexual orientation in society, there is a stark difference between understanding and implementing this, and being accepted in society [15]. Many individuals could be looked on as fortunate that their gender assigned at birth is the one they identify with. Yet, not everybody is as privileged. Between the high costs of surgeries at private healthcare facilities and the lack of sensitivity at both private and government hospitals, sex reassignment surgeries prove to be a tedious process [16]. And, when these patients are referred to with the wrong personal pronouns, they feel mocked, alienated and are less likely to open up to their doctor [17], which in turn results in their actively avoiding healthcare settings to protect themselves from any mental or physical harm from healthcare providers [18].

Understanding gender pronouns

To improve the current situation, one step forward would be for healthcare workers to develop a better understanding of the appropriate terms to use when dealing with a patient. This comes in handy so as to not offend or make presumptuous assumptions about one’s gender or sexual orientation. Table 1 provides a means for this by tabulating the terms imperative for a healthcare professional in relation to SOGI, compiled by the author from the cited sources [19, 20, 21].

Titles also play an important part in the language used towards more sensitive gender-inclusive care. Many titles have been put forward for a gender-inclusive society. One such title added to the Merriam-Webster Dictionary in 2016 is “Mx.” [22], a gender-neutral honorific which could be misinterpreted as “Mix”, but does not imply a “mixed” gender. “RP” which stands for “Respected Person” was proposed by Ladenheim and Wormser [20], with the reasoning that it did not define or imply the gender or marital status of the individual and could be used across the widest range of individuals. Adopting and implementing these titles in daily practice could help to develop a more inclusive approach in improving patient care.

Implementation

Despite it being a herculean task to change the current norms of medical practice, respect is one of the cornerstones of the practice of medicine. Adopting a compassionate outlook and normalising individuals with SOGIESC differing from our own and conventional societal standards is imperative to facilitate a comprehensive patient-doctor relationship.

Hospital databases need a thorough upgrade to include data collection on self-reported gender identity, sexual orientation and characteristics during registration or admission [23]. This information should neither be coerced nor involuntarily extracted from the patient. If a comfortable environment is created between the doctor and the patient, the chances are that the patient will feel safe giving out personal information [24]. Adequate training of the appropriate staff in obtaining this information and privacy on these matters is paramount.

On approaching the patient, assumptions based on one’s appearance, behaviour and other superficial factors should be strictly avoided. Sharing one’s preferred pronouns first, would leave the patient with the choice to share theirs without making it obligatory. Patients may be asked for details regarding their SOGIESC when their parents/guardians are not in the room and the individual’s decision to provide information would thus be respected. The healthcare professional should avoid revealing the patients’ gender identity and pronouns before others without their consent. Gestures such as including gender pronouns in email signatures could be one small but powerful step in improving inclusivity [25]. It provides recognition to matters that might be overlooked by individuals.

A study conducted by Salkind J et al found a significant improvement in the use of the appropriate terminology and language after introducing a compulsory teaching programme in the medical undergraduate curriculum with regards to SOGIESC [26]. Therefore, gender-inclusive discussions via support groups are initiatives which can further educate individuals on the importance of self-identity. Such initiatives may be implemented during healthcare professionals’ education as well as on platforms such as conferences, webinars, etc [27].

Conclusion

By acquainting ourselves with terms frequently encountered with the LGBTQIA+ population, the healthcare fraternity will be better equipped to cater to the needs of our patients while also respecting their autonomy over their SOGIESC and providing inclusive healthcare.

This will not only foster a better relationship with members of the LGBTQIA+ community but will also result in greater participation by the community in medical research and the advancement of technology. Inclusivity and awareness of their rights as human beings and individuals being acknowledged will go a long way towards benefitting society as a whole.