🚧Barriers faced by LGBTQIA+ people in accessing health services

Criminalization, pathologization, and demonization are key drivers of exclusion and marginalization of LGBTQIA+ people. Research shows that they pose significant barriers to LGBTQIA+ people in accessing health services in Malaysia. These drivers can also be categorized as

1. Institutional barriers include laws and policies that criminalize and discriminate against LGBTQIA+ people.

2. Cultural barriers include a lack of knowledge about LGBTQIA+ people and SOGIE.

LGBTIQ and gender-diverse people at times have to disclose their sexual orientation, gender identity, and sex characteristics in order to seek healthcare services that address their needs. This can open them to discrimination, judgment, shaming, and even unnecessary medical interventions. This, in turn, deters them from seeking healthcare services altogether.

In addition, the healthcare system, protocols, and facilities can be gender and sex binary as well as hetero and cisnormative. For example, sexual reproductive health services are designed for cisgender heterosexual women, instead of trans, intersex, and queer women. Meanwhile, health facilities are typically gendered and designed for cisgender men and women.

This section unpacks some institutional, cultural, and other barriers faced by LGBTQIA+ people in seeking healthcare.

👹Criminalization

The criminalization of LGBTQ and gender-diverse people has a ripple effect in increasing stigma and discrimination in Malaysian society. It creates an anti-LGBTQIA+ environment that overwhelmingly impacts access to healthcare and the quality of services.

Criminalization impacts LGBTQIA+ people’s disclosure of sexual orientation and gender identity (SOGI) to healthcare providers and low - even delayed - health-seeking behaviors. Only 53 out of 100 transgender and intersex respondents from a SUHAKAM study (referred to as the SUHAKAM study hereon) felt comfortable disclosing their SOGI to healthcare workers.

In some cases, LGBTQIA+ people’s health issues may not be related to their sexual orientation, gender identity, or sex characteristics, but they may be outed when seeking healthcare, invoking unnecessary or inappropriate attention from healthcare providers. However, some medical conditions do require LGBTQIA+ people to reveal their SOGI to seek medical care or treatment, especially when seeking sexual and reproductive healthcare services. For example, a queer woman may have to disclose her sexual orientation or information about sexual practices to access specific and adequate care for cervical cancer.

When LGBTQIA+ people hide their SOGI Identities or sexual practices, it may result in misdiagnosis, and worsen health conditions due to delayed treatments. A meta-study has found a correlation between positive legal protection of LGBTQ and gender-diverse people and low HIV prevalence rates.

🏳️‍⚧️Lack of legal gender recognition

As transgender and non-binary people are not legally recognized, they face prejudice even when seeking medical care unrelated to their gender and sexual health. For transgender people, this poses a cascading set of barriers to access from the moment of registration (e.g. filling in their name and gender), and being assigned to a ward and receiving care that aligns with their gender. It also leaves transgender and non-binary people vulnerable to prejudice.

A trans woman from the SUHAKAM study reported that she opted for early discharge when she was admitted to a government hospital for dengue fever because of the prejudice and discrimination she experienced from hospital staff, patients, and patients’ visitors. She further shared that she became a topic of gossip among the hospital staff and overheard one of them calling her “pondan”.

🙄Stigma and discrimination

Stigma and discrimination thrive with impunity in the context of criminalization and non-recognition of LGBTQIA+ people. It can manifest in various forms in healthcare settings:

• Microaggression, which can include hostile body language

• Victim blaming for contracting a disease or illness

• Verbal abuse or demonization of SOGI

• Denial of services

• Stereotyping, which includes assuming that all trans women are sexually promiscuous or sex workers

A study shows 42% of 436 physicians in Kuala Lumpur showed stigma-related constructs towards transgender people.

“Due to transgender stigma, physicians may feel shame as a consequence of having a transgender patient or transgender colleague. Physicians may also believe that transgender people do not deserve good care, leading to poor delivery of care. Given the high global burden of HIV among transgender women (i.e., high prevalence of HIV compared to other at-risk groups, including Men who have sex with men [MSM] and persons who inject drugs [PWID]), providers may be prejudiced against transgender women and be afraid of contracting HIV from transgender women, which may in turn contribute to discriminatory treatment. Physicians may also hold stereotypes about transgender people, such as the belief that all transgender people are promiscuous and do not care about their health, which could further contribute to discriminatory treatment.”

The discrimination experienced by LGBTQIA+ people is intersectional and complex.

Case study

Muhammad*, a gay refugee from Afghanistan, experienced discrimination based on his actual or perceived sexual orientation while seeking treatment for HIV at a refugee-friendly clinic in Malaysia. He was asked, “How did you get HIV? Are you gay? Why are you gay? You’re Muslim, you know in Islam it’s haram.”

Key takeaways

• Healthcare providers stigmatizing HIV/AIDS as a gay disease remains one of the main barriers to HIV prevention, testing, and treatment. Muhammad’s experience in the clinic may deter him from going to the same clinic for HIV treatments and further limit his health options as a refugee.

• Healthcare providers should be grounded by the ethical principles of do no harm etc and refer others who could provide them the support that they need (See Section 3 for a full discussion of ethics in care).

Source

No safe haven: What it’s like to be an LGBTIQ+ refugee in Malaysia (Queer Lapis, 2023)

*Names changed to protect confidentiality

🥀Low knowledge of LGBTQIA+ people’s health

The lack of knowledge on LGBTQIA+ specific healthcare concerns and needs, including sexual reproductive health and rights (SRHR) needs coupled with low awareness of SOGIESC, by healthcare providers contributes to poorer quality care. LGBTQIA+ people have reported being asked inappropriate and unnecessary questions during health consultations, resulting in improper diagnosis, and the prescribing of ineffective treatment plans.

The participants of the SUHAKAM study reported receiving jeers, sarcasm, and invasive and pointless inquiries about sex life from medical personnel. They were also recommended for religious or other forms of “therapy” to "cure" their gender identity. A trans woman was advised by a mental health professional to engage with a sex worker to deal with her gender identity, noting that her trans identity was a problem resulting from her mixed-race lineage.

🧑🏾‍🦽Availability and Accessibility

LGBTQIA+ people face additional barriers when their SOGIESC identities intersect with other marginalized identities. This can become more profound in LGBTQIA+ people who live outside the Klang Valley, are elderly, have disabilities, and/or do not have citizenship. Accessibility issues faced by LGBTQIA+ people include:

Lack of accessibility to LGBTQIA+ specific healthcare services. This includes HIV-specific health needs, SRHR needs for queer women, and trans-specific healthcare .

Lack of accessibility to affordable healthcare. One participant in a JFS study shared that from his experience as a community sexual healthcare worker, only 3 out of 10 people who asked about Pre-Exposure Prophylaxis (PrEP) can afford it. People from lower-income groups also face difficulty in accessing LGBTQIA+ affirming care.

Lack of accessibility to culturally competent services, including translation, particularly for people who do not speak, or have limited capability to speak Bahasa Melayu or English.

Specific healthcare service access barriers faced by transgender and gender-diverse people:

Lack of availability of transgender and gender diverse specific health services

Most participants in the SUHAKAM study agreed that the gaps in the healthcare system include:

• Lack of gender-affirming medical procedures and therapy (ie. HRT, surgeries).

• A lack of knowledge on transgender/intersex-specific healthcare needs.

• A lack of dedicated SOGIESC clinics or departments.

• A lack of expertise in trans-specific healthcare services and informed healthcare personnel.

• A lack of health professionals who are compassionate and understanding of the specific consequences of anti-LGBTQIA+ legal and social conditions.

Access to services and facilities based on their gender identity

Trans women in the SUHAKAM study reported that they were put in a male ward based on their IC and had to confirm their gender to the medical staff by showing them their genitalia. They were subject to inappropriate examination by a medical practitioner, which constitutes sexual harassment. This underscores a lack of transgender-inclusive policies in healthcare facilities as well as the lack of legal gender recognition for trans and non-binary persons.