# Health gaps faced by LGBTQIA+ people Research on health issues and disparities faced by LGBTQIA+ people in Malaysia is limited. Globally, Lesbian Bisexual Queer (LBQ) women are reportedly at a higher risk of [cervical](https://www.liebertpub.com/doi/10.1089/jwh.2009.1393), [breast](https://www.liebertpub.com/doi/10.1089/jwh.2007.0447), and [ovarian cancer](https://cancer-network.org/cancer-information/bisexuals-and-cancer/bisexual-women-and-ovarian-cancer/). Unfortunately, such information is not available in Malaysia. The information gap correlates with the absence of affirming and tailored care for LGBTQIA+ people. LGBTQIA+ affirming health services in Malaysia is underdeveloped at best, or non-existent at worst. Primary care for LGBTQIA+ patients should be tailored to each individual while also taking into account the unique risks and behaviors connected to various groups. ## šŸŖ¬Mental health concerns {% hint style="success" %} i.e. Depressive Disorders, Anxiety Disorders, Post Traumatic Stress Disorder (PTSD), Eating Disorders, self-harm/suicide. {% endhint %} A [2022 research on coping strategies and mental disorders among the LGBT+ persons in Malaysia](https://www.mdpi.com/2227-9032/10/10/1885) indicates that the prevalence of mental disorders among the self-identifying LGBT+ adult population is more than double that of the general population (80.3% vs. 29.2%). Among the specific mental disorders, the one with the highest prevalence is Major Depressive Disorder, which is at least 3 times (40.1% vs. 12%) and as high as 20 times (40.1% vs. 2.3%) more prevalent than in the Malaysian general population. This stems from institutionalized prejudice, social stress, social exclusion, discriminatory hate and violence, and internalized guilt and shame.
Further reading * [Queer Affirmative Counseling Practice Resource Book](https://mhi.org.in/qacp/)
## šŸ¦„Gender Dysphoria Gender dysphoria is a form of stress commonly faced by transgender and non-binary people due to the dissonance between a person's self-perception and identification of their gender identity and societal perception and identification. The lack of legal gender recognition, criminalization of trans peopleā€™s gender expression and gender identity, fatwa against gender affirming procedures, and social exclusion can further exacerbate gender dysphoria. In a context where trans specific healthcare is unavailable, unaddressed gender dysphoria can have severe impact on a personā€™s mental health, including [suicidal ideation and self-harm](https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642\(22\)00280-2/abstract). In some cases, parents of young trans and non-binary people may pressure them to seek mental health support, and even accompany them at times, to correct their gender identity, instead of supporting them to express who they are. In such cases, it is important to provide parents with accurate information and not dismiss the child or young personā€™s gender identity and gender expression because of their age. Healthcare providers should create a safe and enabling environment for the child and young people to express, explore, and discover themselves.
Further reading * [Standards of Care - WPATH](https://wpath.org/publications/soc) * [APTN Blueprint](https://weareaptn.org/wp-content/uploads/2017/10/blueprint-comprehensive.pdf) * [Practical Guidelines for Trans-Specific Primary Healthcare in Malaysia](https://galencentre.org/wp-content/uploads/2020/11/Final-Practical-Guidelines-for-Trans-Specific-PHC.pdf)
{% hint style="danger" %} **Legal gender recognition and gender dysphoria** A Justice for Sistersā€™ research shows the relationship between lack of gender recognition and gender dysphoria. Aya explains that the non-recognition of her gender identity causes her gender dysphoria every time she presents her official documents. In Malaysia, official documents are used for almost everything from being able to enter a building to applying for a bank loan. She explains: *I think the biggest challenge in terms of society is because of the official documents, they obviously do not recognize transgender people, so whenever I present an official document is when I feel the most dysphoric. And I would always fear what other people would say to me or what they are thinking, or they ask a lot of questions, itā€™s always a very traumatic event. ā€¦ The only thing I would like to add is that to have legal gender recognition. That would help a lot as well. For us, we have to change our legal documents. If not, otherwise I think no matter how well we pass or whenever we go through any official positions where we have to show our official documents, we would feel dysphoria and I think none of us can escape. That would be the one thing that could help us being transgender.* {% endhint %} ## šŸ˜µā€šŸ’«Sex or gender normalizing surgery The Malaysian Pediatric Protocols require intersex babies to be diagnosed with Disorder of Sexual Development (DSD) and [prescribed unnecessary ā€œcorrectiveā€ surgeries and procedures](https://www.queerlapis.com/intersex-issues-msia/) to alter the babyā€™s genitals to appear compatible with their assigned gender. The SUHAKAM study revealed that intersex individuals in Malaysia encounter discrimination and rights infringements beyond involuntary surgeries. Findings from medical research in 2017 indicate that a considerable portion of intersex children have undergone non-consensual genital surgeries, leading to [diminished quality of life and academic achievement](https://pubmed.ncbi.nlm.nih.gov/28965114/).
Further reading * [Intersex-affirming hospital policies](https://legacy.lambdalegal.org/sites/default/files/publications/downloads/resource_20180731_hospital-policies-intersex.pdf) * [Intersex Awareness](https://www.unfe.org/en/what-we-do/our-campaigns/intersex-awareness) (UN Free & Equal) * [Intersex people: OHCHR and the human rights of LGBTI people](https://www.ohchr.org/en/sexual-orientation-and-gender-identity/intersex-people)
## šŸ·Substance use (ie. alcohol, cigarettes, drugs) Similar to other populations, LGBTQIA+ people may resort to substance use for a range of reasons - [to cope with gender dysphoria](https://www.undp.org/asia-pacific/publications/blueprint-provision-comprehensive-care-trans-people-and-trans-communities-asia-and-pacific), discrimination-related stresses, trauma, [sexual activities](https://pubmed.ncbi.nlm.nih.gov/29605540/); therapeutic reasons; recreational reasons; and pleasure, among others. This coping mechanism can lead to the development of detrimental substance use habits and dependency. Additionally, the fear of facing judgment from healthcare providers [may deter them from seeking assistance for substance use disorders, including dependency](https://www.undp.org/asia-pacific/publications/blueprint-provision-comprehensive-care-trans-people-and-trans-communities-asia-and-pacific). Studies on substance use among LGBTQIA+ people consistently show that LGBTQIA+ people use substances to cope with trauma. A 2021 study shows MSM or GBQ men use substances as a [coping mechanism for the stigma](https://www.aidsdatahub.org/sites/default/files/resource/apcom-qualitative-scoping-review-sexualised-drug-use-including-chemsex-2021.pdf) associated with an HIV diagnosis. Specifically, MSM or GBQ men often attempt to [use chemsex to escape emotional pain](https://www.sciencedirect.com/science/article/abs/pii/S0955395918300586?via%3Dihub) and feelings of lost social worth. "Chemsex" or sexualized drug use among GBQ men is commonly discussed, even though studies on the subject matter is limited, [owing to the double criminalization of drug use and LGBTQ and gender-diverse people](https://www.mdpi.com/1660-4601/20/1/294). Another study showed trans women sex workers [using drugs to cope with violence from their clients](https://oarep.usim.edu.my/jspui/bitstream/123456789/10340/1/Bab%2018%20Psychosocial%20Review%20On%20Substance%20Use%20Among%20Youth%20Transgender%20In%20Penang,%20Malaysia.pdf). Transgender respondents in the same study noted that trans women who inject drugs face not only stigma from the general population [but also within the trans population](https://oarep.usim.edu.my/jspui/bitstream/123456789/10340/1/Bab%2018%20Psychosocial%20Review%20On%20Substance%20Use%20Among%20Youth%20Transgender%20In%20Penang,%20Malaysia.pdf).
Further reading * [Care for Addiction](https://www.lgbtqiahealtheducation.org/wp-content/uploads/2016/11/Keuroghlian-Addictions-Webinar.pdf) * [Substance Abuse Treatment for LGBT people](https://store.samhsa.gov/product/Providers-Introduction-Substance-Abuse-Treatment-Lesbian-Gay-Bisexual-Transgender/SMA12-4104)
## šŸ‘Sexual reproductive health needs (SRHR) Sexual reproductive health (SRH) needs and rights of LGBTQIA+ people are understudied and researched in Malaysia. Existing studies largely focus on HIV and STIs. LGBTQIA+ people [may not have access to sexual reproductive health services](https://www.undp.org/asia-pacific/publications/blueprint-provision-comprehensive-care-trans-people-and-trans-communities-asia-and-pacific) therefore leading to barriers to accessing contraception and family planning, gender-affirming care, and appropriate sexual awareness and education about their SOGI. LGBTQIA+ people have [reported doctors not being knowledgeable about their SRH needs](https://outrightinternational.org/sites/default/files/2022-10/MalaysiaCC_0.pdf). Anecdotal evidence shows that LGBTQIA+ people have [various unmet needs](https://outrightinternational.org/sites/default/files/2022-10/MalaysiaCC_0.pdf) including sexual health check-ups for trans people, pap smear check-ups for LBQ women, pregnancy and abortion, etc.
Further reading * [Taking routine histories for sexual health](https://www.lgbtqiahealtheducation.org/wp-content/uploads/COM-827-sexual-history_toolkit_2015.pdf) * [8 Pā€™s of sexual history](https://weareaptn.org/wp-content/uploads/2021/12/English_22.08.23.pdf) * [Manual for Sexual Health Advisers](https://www.ssha.info/wp-content/uploads/ha_manual_2004_complete.pdf) * [Asexualā€‘Identified Adults: Interactions with Healthā€‘Care Practitioners](https://sci-hub.se/https://pubmed.ncbi.nlm.nih.gov/32222850/)
## šŸ§£HIV, STIs LGBTQIA+ people have increased risk of HIV and STIs due to institutional barriers, with criminalization playing a large role. People in countries where same-sex relations are criminalized are more than twice as likely to be HIV-positive as those in countries without such legal penalties. In countries with severe criminalization, the [likelihood of being HIV-positive is nearly five times higher](https://www.unaids.org/sites/default/files/media_asset/03-hiv-human-rights-factsheet-gay-men_en.pdf) than in countries without such legal consequences. Additionally, the [awareness of HIV status among GBQ men and MSM who are HIV-positive was significantly greater](https://www.unaids.org/sites/default/files/media_asset/03-hiv-human-rights-factsheet-gay-men_en.pdf) in countries with the least restrictive laws on LGBTQIA+ people compared to those with the most stringent regulations. Given the general lack of sexual awareness and education as well as access to health services, LGBTQIA+ people [may not have access to](https://arrow.org.my/wp-content/uploads/2021/01/LGBTIQ-Rights-in-Malaysia-.pdf) information, regular testing, prevention methods and treatments when it comes to HIV and STIs.
Further reading * [A guide in taking sexual history](https://www.cdc.gov/std/treatment/sexualhistory.pdf) * [APTN Blueprint](https://weareaptn.org/wp-content/uploads/2017/10/blueprint-comprehensive.pdf)
## šŸ‘æViolence LGBTQIA+ people are vulnerable to various forms of violence from various actors. Health care providers must be aware of the factors that contribute to the violence, and the consequences on LGBTQIA+ people. For example, Intimate Partner Violence (IPV) among LGBTQIA+ people has a higher impact because victims are unable to access social and/or family support, or make police reports. It was reported that LGBTQIA+ people are [hesitant to seek support and report instances of abuse due to concerns about](https://outrightinternational.org/sites/default/files/2022-10/MalaysiaCC_0.pdf) potential exposure of their identity, evade additional ridicule, harassment and even arrest from authorities due to criminalization of LGBTQ people, and lack of sensitivity and familiarity of LGBTQIA+ peopleā€™s needs. [A trans man who experienced sexual violence](https://www.hrw.org/sites/default/files/reports/malaysia0914_ForUpload.pdf) did not seek support due to the prospect of revealing his genitalia to a doctor: ā€œI was embarrassed. I couldnā€™t seek help. I would have to explain all these things, reveal my ā€˜parts.ā€™ā€ Meanwhile, GBQ men who have experienced sexual violence fear reporting such cases due to fear of arrest given the criminalisation of carnal intercourse.
Further reading * [LGBT Best Practices for Survivors of Domestic Violence and Sexual Assault](https://nnedv.org/wp-content/uploads/2019/06/Final-LGBT-Manual_Revised_113015_SC.pdf), * [IPV systemic review](https://link.springer.com/article/10.1007/s13178-022-00761-4).
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