Association Between Knowledge, Attitude, Social Contact and Social Distance Practices with Regard to the LGBT Community Among Heterosexual Individuals Living in the Punjab State of India

Kar A., Das N., Broadway-Horner M., Kumar P.

Intimate partner violence (IPV) has been a significant public health problem in same-sex relationships. However, health policies across the globe do not address IPV causing a massive gap in health and economic burden. In the last decade, crucial missing links have been established, and researchers tried to connect the dots of this severe health disparity. This intersectionality has found the impact of race, gender, class, physical ability, and legal framework of IPV in lesbian, gay, and bisexual (LGB) relationships. However, preventive strategies, training programs, and dialogues in the clinical field about IPV are from heteronormative lenses. This particular bias can perpetuate the issue and will remain one of the leading causes of health burden in the LGB population. This article reviews the lacunae in health policies regarding same-sex IPV, highlights its impact on minority mental health, and calls for attention to train health-care professionals regarding the same.

Bhugra D., Killaspy H., Kar A., Levin S., Chumakov E., Rogoza D., Harvey C., Bagga H., Owino – Wamari Y., Everall I., Bishop A., Javate K.R., Westmore I., Ahuja A., Torales J., et. al.

Sexual orientation is a key determinant of the identity of human beings. It has also been seen as a social determinant of health. People whose sexual orientation is non-heterosexual or sexual minorities or sexually diverse are included in the broad umbrella term LGBT (Lesbian, Gay, Bisexual, and Transgender) which is a commonly used acronym in activism, social policy, and subsequently cultural literature. For this reason, this Commission focuses primarily on sexual orientation i.e. lesbian, gay and bisexual (LGB) groups. We have used terms non-heterosexual, sexual minorities or sexual variation interchangeably. We have not considered asexual individuals as research in the field is too limited. We are cognisant of the fact that topics relating to mental health and sexual orientation discussed in this Commission will intersect with other issues of personal, cultural and social identity, and will thus be relevant to individuals including many transgender individuals. The inclusion of mental health issues relevant to gender-diverse individuals as well as gender identity is important and deserves its own separate detailed discussion. The exact number of sexually diverse individuals in a population is often difficult to estimate but is likely to be somewhere around 5% of the population. Rates of various psychiatry disorders and suicidal ideation and acts of suicide in LGB populations are higher than general population and these have been attributed to minority stress hypothesis. Elimination of inequality in law can lead to reduction in psychiatric morbidity in these groups. However, these are all diverse groups but even within each group there is diversity and each individual has a distinct and unique experiences, upbringing, responses to their own sexual orientation, and generating varying responses from families, peers and friends as well as communities (including healthcare professionals). The mental healthcare needs of sexual minority individuals vary and these variations must be taken into account in design, development and delivery of healthcare and policies. Improving access to services will help engagement and outcomes and also reduce stigma. The commission recommends that there is no role for so-called conversion therapies and other recommendations are made for clinicians, researchers and policymakers.

Miller R.K., O’Neill D., Pua Y.K., Atkinson C.M., Martin F.H.

Kar A., Arneaud G.J., Majumder S., Bhugra D., Pal A.

The Supreme Court of India, decriminalized same-sex activities in 2018 but the Indian medical curriculum has not been updated and inclusive of the sexual minorities despite the change. This study explores the attitude of medical students towards same-gender attraction and how it has shaped and reshaped in an ever-changing social environment. Medical students of four reputed Indian medical colleges were asked to self-administer an 18-item questionnaire anonymously. Internal consistency of the questionnaire statements was high. Of 729 initial responses, 84 were omitted for giving incomplete responses and 3 were omitted for not being Indian. A total of 642 responses was included in the analysis. More than 80% of the students believed homosexuality is a sexual orientation whereas only 15% believed it is an acquired behaviour and only 1.9% considered it an illness. However, more than 95%of students agreed that homosexuality is not an illness. Although the overall attitude of Indian medical students has changed since decriminalization, urgent work on the medical curriculum is needed to change some negative attitudes so that patients receive appropriate care.

Saraff S., Singh T., Kaur H., Biswal R.

Lim D., Ang S.B.

This study aim to gain insights into attitudes, acceptance and knowledge levels among family physicians toward homosexual people, which are important as they may affect care among this at-risk group. An anonymized self-administered questionnaire in English was posted with the assistance of the College of Family Physicians Singapore in February 2015 to its 1 529 members with self-addressed, pre-stamped envelopes for replies. The questionnaire included demographic questions such as age group, gender, religion, ethnicity, marital status and place of practice. Questions and scales that measured attitude, acceptance, knowledge and perception of colleagues who are homosexual were also included in the questionnaire. 451 responses (29.5%) were obtained, of which 441 were valid (28.84%). About 52.8% of participants were found to have negative, 8.9% neutral and 38.3% positive attitudes toward homosexuality. Most (75.6%) were accepting of homosexuals, with 9.3% neutral and 15.1% not accepting. Knowledge levels were poor, with a mean score of 6.9 out of a maximum of 13. A strong correlation was found between the attitudes towards lesbians and gay men (ATLG) and acceptance of homosexuals scales ( r = 0.69, P < 0.001), with moderate correlations between acceptance and knowledge ( r = 0.54, P < 0.001) and ATLG and Knowledge ( r = 0.54, P < 0.001). Despite majority of family physicians having negative attitudes towards homosexuality, most are able to accept homosexuality. With better education in sexual orientation in the medical educational curriculum, the increase in knowledge will lead to better care for people with homosexuality.

Majumder S., Kar A.

Miller R.K., O’Neill D., Bhuyan D.J., Martin F.H.

Tandon A., Rao T.S.

Pufahl J., Rawat S., Chaudary J., Shiff N.J.

Objectives This project aimed to assess the effectiveness of a community-based theatre intervention to improve attitudes towards and increase knowledge about LGBTQ+ communities among audiences in Mumbai, India. Study design This study was a program evaluation using pre- and post-show surveys that incorporated an adapted version of The Riddle Scale: Attitudes Towards Difference and questions assessing self-reported knowledge about LGBTQ+-related issues to assess changes in attitudes and knowledge after viewing the theatre intervention. Methods An original 90-min devised play was created by a company of Indian, American, and Canadian theatre artists using Participatory Action Research methods and was designed to bring audiences to a deeper understanding of LGBTQ+ identity. The show was performed four times in Mumbai, India, and pre-/post-show surveys were collected at each performance. Audience survey responses were analysed using parametric and non-parametric descriptive statistics as appropriate, and Likert scale questions were compared using Wilcoxon Signed Rank for non-parametric data. Results A total 184 surveys were completed across four performances between March 7 and 14, 2020. Significant increases in audiences’ self-reported knowledge of LGBTQ+ identity, impacts of discrimination, and struggles faced by LGBTQ+ communities were reported after viewing the show. Furthermore, attitudes towards LGBTQ+ rights, understanding of the challenges of being LGBTQ+ in India, and recognition of the contributions LGBTQ+ individuals make to society improved significantly among our audiences after test. The play further fostered increased acceptance of prosocial behaviours towards LGBTQ+ individuals with higher percentages of audiences recognizing the importance of standing up to homophobia and anti-gay attitudes. While these observations were seen across audiences, they were particularly pronounced among cisgender heterosexual men and audiences ages 18–24. Conclusion Community-based theatre intervention is highly acceptable and effective as a medium for informing positive attitudes, improving knowledge, and promoting acceptance of and solidarity towards LGBTQ+ communities among young adult heterosexual audiences.

Chakrapani V., Scheim A.I., Newman P.A., Shunmugam M., Rawat S., Baruah D., Bhatter A., Nelson R., Jaya A., Kaur M.

Research on transmasculine people's health is scant globally, including in India. We explored transmasculine people's experiences in affirming their gender in family and social spaces, and how those experiences impact mental health. In 2019, we conducted four focus groups (n = 17 participants) and 10 in-depth interviews with transmasculine people in Mumbai and Chennai. Data analyses were guided by minority stress theory and the gender affirmation model. Within family, the pressure to conform to assigned gender roles and gender policing usually began in adolescence and increased over time. Some participants left parental homes due to violence. In educational settings, participants described the enforcement of gender-normative dress codes, lack of faculty support, and bullying victimisation, which led some to quit schooling. In the workplace, experiences varied depending on whether participants were visibly trans or had an incongruence between their identity documents and gender identity. Everyday discrimination experiences in diverse settings contributed to psychological distress. Amidst these challenges, participants reported resilience strategies, including self-acceptance, connecting with peers, strategic (non)disclosure, and circumventing gendered restrictions on dress and behaviour. Interventions at social-structural, institutional, family and individual levels are needed to reduce stigma and discrimination faced by transmasculine people in India and to promote their mental health.

Arvind A., Pandya A., Amin L., Aggarwal M., Agrawal D., Tiwari K., Singh S., Nemkul M., Agarwal P.

Sartaj D., Krishnan V., Rao R., Ambekar A., Dhingra N., Sharan P.

Purpose: The Hijra community is a cultural and gender grouping in South Asia broadly similar to western transgender communities, but with literature suggesting some differences in gender experience and patterns of psychosocial adversity. The present study aims to describe patterns of mental illness and psychoactive substance use in Hijra subjects and study their association with gender experience and psychosocial adversity. Methods: Fifty self-identified Hijras availing HIV-prevention services in New Delhi, India, were interviewed. Data on mental disorders, psychoactive substance use, quality of life, discrimination, empowerment, violence and gender identity were assessed using structured instruments. Results: Subjects were mostly in their mid-twenties, and had joined the Hijra community in their mid-teens. More subjects (46%) were involved in begging than in traditional Hijra roles (38%). Sex work was reported by 28% subjects. The rates of lifetime mental illness was 38%, most commonly alcohol abuse (26%); others had anxiety or depressive disorders (8% each), somatoform disorders (6%) and bulimia nervosa ( n = 1). Disempowerment was mostly experienced in domains of autonomy and community participation; 52% had experienced sexual or psychological violence. Discrimination was attributed to gender (100%), appearance (28%) or sexual orientation (28%). There were negative correlations between the physical domain of WHO-QOL and physical violence and depression scores; and between discrimination and WHO-QOL environmental, physical and psychological domains. Conclusions: This Hijra group showed high rates of mental disorder and substance involvement, related to QOL domains and experiences of discrimination and disempowerment.

Kar A., Bhugra D., Mukherjee S., Mondal A., Kumar A.S.

Introduction: The global revolution of online social media and connectivity had a tremendous effect on sexual behavior in both developed and developing countries. This global change is influencing the societal structure and existing social principles. Moreover, it has a significant impact on the epidemiology of different infectious diseases, especially HIV.Discussion: India is one of the most diverse democratic countries that has undergone a social-cultural transition in the last decade. However, having the second-highest HIV infection rate in the world, India does not have any other new prevention tools in their national HIV prevention strategy. Pre-Exposure Prophylaxis (PrEP), a boon of HIV prevention widely used in different countries, is still not implemented in India. The concept of “Digital India” by the Government of India is giving wide access of internet to the people of India. Furthermore, people are exposed to social media, and that is impacting their sex seeking behavior. Interestingly, recent legal changes in India promotes sex positivity. It also calls for introspection on existing HIV preventive strategies.Conclusion: Given the current scenario of PrEP and other existing preventive measurements of HIV, further research is needed to determine the acceptance and efficacy of PrEP and improve engagement in care for individuals in India. Various international studies recommend effective implication of PrEP to reduce the rate and economic burden of HIV infection.

Wandrekar J.R., Nigudkar A.S.

Background: The period from 2009 to 2019 has seen a lot of conversation about issues of LGBTQIA+ (lesbian, gay, bisexual, transgender, queer/ questioning, intersex, asexual, and others) individuals in India, but they continue to be a group showing poor health equity. Objective: This descriptive content review attempted to explore 5 questions: what is the nature of existing research on mental health of LGBTQIA+ individuals, what are the pathways that contribute to mental health issues, whether the existing health facilities mitigate or facilitate these pathways, what are the interventions proposed for this group, and what are the gaps in research that can be addressed in the next decade. Method: “Mental health aspects” were described as variables relevant to understanding individuals’ cognitions, emotions, and behavior. We searched for literature in online journal databases, in archives of the most prominent journals, on websites of prominent LGBTQIA+ organizations, and through cross-referencing of papers obtained. The data were abstracted and coded into themes and subthemes. We found 22 reviews and reports, 4 viewpoints and comments, 7 editorials, 1 conference proceeding, and 60 original articles. Conclusions: Prevalence studies reveal that LGBTQIA+ individuals were found to show high rates of mental health concerns, and that the adapted minority stress model may be a crucial pathway for the same. Lived experiences, factors related to mental well-being, and societal attitudes have also been studied. Intervention studies are relatively fewer, and certain subgroups of LGBTQIA+ identities are less represented in research. Gaps in research were identified and recommendations for research in the coming decade were proposed.