Need of LGBTQ+ Curriculum in Nepalese Medical Education

Abstract

The need for LGBTQ+ inclusivity in medical education and their active enrollment in healthcare delivery is evident in Nepal due to ongoing healthcare disparities. These inequities, resulting from barriers in access, discrimination, and provider bias, demand an immediate action. To address these issues effectively, a deliberate shift in medical education is crucial. This involves making LGBTQ+ content a compulsory part of the curriculum, providing comprehensive instruction on sexual orientation and gender identity, and training students to create inclusive, respectful healthcare settings. This transformation aims to ensure equitable, respectful, and dignified care for LGBTQ+ patients, underlining the pivotal role of faculty development and training. By integrating LGBTQ+ health topics into the curriculum and promoting a culture of inclusivity, medical schools and institutions can produce healthcare providers who are not only knowledgeable but also compassionate and culturally competent in their practice.

Status of the LGBTQ+ Communities in Nepal

LGBTQ+ individuals are now more prominent in the society and, thus in the healthcare setting. The “+” in LGBTQ+ represents the inclusivity for diverse identities, allowing the community to expand, language to evolve, and individuals to describe themselves authentically. ¹ The exact prevalence of LGBTQ+ population in Nepal is still unknown. Nepal's census of 2021 estimated that around 2928 people identified as lesbian, gay, bisexual, transgender, intersex, or other diverse sexual or gender identities in Nepalese communities. ² The absence of specific questions and data collection methods in the census, coupled with concerns about privacy, resulted in most of the population underreporting. However, LGBTQ+ rights groups estimated a much higher number, around 2.5 million LGBTQ+ individuals in the country. ²

In recent years, Nepal has made large strides in pro-LGBTQ+ policy. Several legislative changes have improved the lives of LGBTQ+ individuals in Nepal. In 2007, a “third gender” was legally recognized, and an audit was conducted to identify all laws that discriminated against LGBTQ+ people. Later, the “third gender” was added to voting polls and the federal census. The supreme court of Nepal has also ruled in favor of same-sex marriage in 2008.^3-6 The Blue Diamond Society (BDS) in Nepal operates the “BDS Care and Support Centre,” providing complimentary hospice and palliative care for LGBTQ+ individuals dealing with chronic or terminal illnesses. ⁷

Despite legislative changes, same-sex sexual orientation is still stigmatized in Nepal, where an estimated 900,000 LGBTQ+ face harassment and discrimination in daily life and healthcare settings. ⁸ Mental illness, suicide, substance use, obesity, sexually transmitted infections (STIs), and the risk of heart disease, along with other health outcomes, disproportionately affect the LGBTQ+ population at higher level compared to the whole population broadly. ⁹ This can be partially attributed to higher reluctance among LGBTQ+ members to seek treatment from healthcare providers due to the stigma they encounter, which may not be experienced by the rest of the population. ⁵

Health Disparities Faced by LGBTQ+ Individuals

LGBTQ+ individuals in Nepal experience health disparities across different life stages, influenced by stigma, discrimination, and societal norms. During childhood and adolescence, they face mental health challenges. In 2022, National Survey on LGBTQ+ Youth Mental Health conducted by The Trevor Project; it was found that LGBTQ+ children who experienced homophobic bullying had double the likelihood of suicide attempts compared to their peers. ¹⁰ In turn, they might involve in substance use to cope with minority stress and negative experiences in unsupportive anti-LGBTQ+ environments. ¹⁰ In early/middle adulthood, there is a struggle to meet societal norms that favor heterosexual relationships and identities, leading to mood disorders and disparities in accessing healthcare. Later adulthood sees continued stigma and victimization, impacting mental health and crisis competence. HIV and STIs remain significant concerns across all age groups. Discrimination, along with the lack of information and support, often contributes to these disparities. ¹¹

LGBTQ+ individuals face unique health disparities, with each subgroup having distinct concerns influenced by factors such as caste, ethnicity, socioeconomic status, geography, age, gender, and HIV status. Recognizing these differences is vital, as they are often inaccurately grouped under broad terms such as “third gender” or LGBTQ+. ¹¹ Internalized homophobia, driven by fear and shame upon disclosing one's sexual orientation, combines with external homophobia, such as misconduct and abuse from healthcare professionals often discourages LGBTQ+ individuals from seeking professional care initially. ⁹ This exclusion and marginalization in healthcare results in reduced attendance, driving many to resort to self-medication, leading to delayed care and potentially worsening health conditions.^12,13

Many Nepali transgender individuals face health risks due to insufficient knowledge about the side effects and hazards of hormone supplements, often administered by healthcare professionals for financial gain without proper explanation. Unsupervised hormone uses leads to fatal short- and long-term adverse effects. ¹³ Emerging evidence has linked hormone use to health risks such as venous thromboembolism, elevated liver enzymes, gallstones, decreased hemoglobin, low sexual desire, reduced facial/body hair, and increased myocardial infarction or depression. ¹³ Moreover, LGBTQ+ access preventive healthcare services less frequently. Transgender men struggle to access sanitary pads, impacting hygiene during menstruation. Many transgender adults undergo hormone therapy and surgeries without awareness of health complications. The legal status of sex-reassignment surgery is unclear, although postoperative individuals can change their official identity. ¹¹ However, these groups later face challenges in updating their citizenship certificates post trans-surgery, even in Kathmandu, leading to legal issues throughout their lives. ⁷ Authorities restrict these individuals from participating in health conferences abroad simply because their passport photo does not align with their current appearance. ¹⁴

These nonbinary individuals do not exclusively identify themselves as male or female, embracing a diverse gender spectrum. With distinct health requirements such as gender-affirming surgeries and hormone treatments, they may also need guidance on family planning and sexual health protection. In cases where these services are inadequately accessible, some may resort to unregulated healthcare providers for assistance. ⁵

Confidentiality concerns, difficulty making appointments, and discomfort with gendered wards contribute to obstacles in accessing healthcare for sexual minorities. Some resort to using others’ identities to avoid societal identification by doctors. ¹⁴ In a human rights violations report, a transgender individual highlighted the challenges they face in healthcare, citing professionals’ lack of understanding and reluctance to treat them. Discrimination based on perceived associations with sex work or HIV-positive status further stops their access to healthcare. The fear of judgment and punishment from untrained healthcare professionals deters sexual minorities from seeking medical treatment, infringing on their right to health. ¹⁵

With increased visibility of LGBTQ+ individuals and their health issues in society, healthcare professionals acknowledge that they often encounter diverse patients during their practices and need to be knowledgeable and sensitive about their unique needs to deliver equitable care to these individuals, just as they would for any other patient. ¹⁶

Current Medical Curriculum in Nepal

Medical education system of Nepal is flawed, with research revealing poor knowledge and attitudes among Nepalese medical students toward the LGBTQ+ community. A 2017 study conducted among medical students in a medical college of Nepal showed that students had poor knowledge and a negative attitude regarding LGBTQ+ individuals compared to other countries. ¹⁷ Medical education is offered in various colleges under different institutions, each with its own curriculum. However, all of these curricula maintain a traditional view that sees heterosexuality as the norm.

The curriculum superficially covers infectious diseases such as HIV or STIs prevalent among LGBTQ+ individuals, but it lacks depth in other crucial areas. Topics such as mental health disparities, hormone therapy, gender-affirming care, and sexual health outside of STIs are often overlooked. Patient history forms only offer options for male or female, making LGBTQ+ individuals hesitant to share important information with healthcare providers, which can complicate clinical diagnoses. ⁷

Guidelines and training resources for LGBTQ+ healthcare is available, however yet they lack rigorous evaluation, and their reach is limited in low and middle-income countries including Nepal. ¹⁸ Deep-seated negative attitudes toward the LGBTQ+ communities have declined the motivation among Nepalese students to access educational resources to acquire necessary knowledge and skills. ¹⁸

Limited access to LGBTQ+ health curriculum in Nepalese medical institutions hinders addressing key health needs of local LGBTQ+ communities, which mainly include training healthcare provider to combat stigma, improved HIV outreach, nondiscriminatory access to healthcare, tackling sanitation, and reproductive health concerns. ⁵ In many cases, healthcare providers are not knowledgeable about the health care needs of transgender and gender nonconforming individuals who do not identify with the binary man and woman gender identities. ¹¹

This gap in education leaves medical students ill-equipped to address the holistic healthcare needs of LGBTQ+ individuals. Hence, there is a pressing need to expand the curriculum to encompass a broader spectrum of LGBTQ+ health issues, ensuring comprehensive and inclusive medical education. Research is essential to advocate for changes in the medical curriculum to address the diverse health needs of all individuals in the country.

Potential Changes for LGBTQ+ Inclusivity in Medical Curriculum

Inclusive care involves not only understanding the medical aspects of LGBTQ+ health but also fostering cultural competence and sensitivity among healthcare providers. It requires an appreciation of the diversity within the LGBTQ+ community, acknowledging that each individual's experiences and healthcare needs may be different. In this regard, medical schools can serve as an important platform for tackling these issues through training and inclusive curriculum development. The curriculum should encompass comprehensive instructions on the biology of sexual orientation and gender identity, addressing the prevalent health concerns common among LGBTQ+ patients during core classes. ¹⁹ This would assist clinicians to identify their patients’ sexual orientation and gender identity enabling them to address specific concerns such as behavioral health, HIV prevention, and transgender care. ²⁰

It is essential to offer training during preclinical stages to ensure respectful interactions and competent evaluation of these patients, as research shows that some may avoid seeking medical care due to concerns about potential discrimination and insensitive attitudes from untrained healthcare providers. ¹⁹ Trainings should include evidence-based clinical information specific to the LGBTQ+ population. Teaching medical students how to establish a welcoming environment for LGBTQ+ patients, develop rapport, and ensure an inclusivity is essential. The curriculum committee should introduce LGBTQ+ patient care training during the initial 2 years of medical school. Incorporating LGBTQ+ concerns in teaching sexual history taking and relevant questionnaires in medical interviews (eg, “Tell me about your last relationship”) can facilitate patient disclose their sexual orientation at their own pace without any sort of hesitations. ¹⁶ Sexually transmitted infections prevalent among LGBTQ+ individuals (such as monkeypox, HIV, and AIDS) are included in the curriculum with increased emphasis on MSM and trans gender as a group. ¹⁹ However, various subpopulations within the LGBTQ+ community, including sexual minority women, those identifying as bisexual, and individuals with nonbinary gender identities are often left unaddressed. ²¹ Therefore, further curriculum development should aim to address these critical gaps. It is equally essential to include broader LGBTQ+ health issues such as diverse hormone therapy options with their pros and cons, in the curricula to avoid stigmatization. ¹⁹ Medical schools in developing nations should prioritize LGBTQ+ medicine by offering elective clinical rotations focused on LGBTQ+ patient needs.

The adoption of case-based teaching methods, grounded in constructivism and situational learning theory, can be particularly effective. ²² This involves challenging traditional assumptions and adopting LGBTQ+ pedagogies that encourage a broader understanding of gender and diverse patient experiences. ²³ By incorporating real-life cases and fostering discussions on these topics can empower medical students to navigate the complexities of LGBTQ+ health issues, develop critical thinking skills, and enhance their competency in providing inclusive healthcare.^22,24,25 For the successful implementation, educators and specialists from transgender communities should be hired to bring firsthand experiences into the curriculum. ²³

Intervention strategies, including Continuing education, can be implemented to prepare healthcare professionals for providing nondiscriminatory services to the LGBTQ+ community. ⁹ With this knowledge, physicians can assist LGBTQ+ patients in addressing questions about their sexuality and process of coming out to themselves in similar manner to how they address other social or mental health concerns and make referrals when necessary. ²⁶ Though not all clinicians need to specialize in LGBTQ+ health, they should be equipped to address the specific health concerns of this population. ²⁰

Most traditional residency and fellowship programs lack integration of social determinants of health, despite their substantial impact on patients. ²¹ Physicians should recognize these challenges faced by LGBTQ+ individuals, including adolescents at risk of suicide or adults coming to terms with their sexual orientation later in life, often feeling isolated. ²⁶ Nevertheless, guidelines for care can be straight forward: ask relevant questions, provide an open and nonjudgmental environment for discussing risk behaviors, inquire about their life situations, relationships, and support systems, and offer referrals for counseling and support as needed.^9,26 Adopting these practices is vital to enhance healthcare accessibility, protect confidentiality, and prevent discrimination. ⁹ However, to effectively address this topic to medical students, institutions must ensure that faculty are competent and comfortable with the material. ²¹

Healthcare facilities need to establish sensitive, responsive policies and spaces that ensure confidentiality for LGBTQ+ individuals. ⁵ Rigorous research and development are crucial to understanding the health implications of hormone use, including proper counseling on medication, dosage, and surgery. Psychological support is integral in addressing gender dysphoria, highlighting the importance of tailored healthcare for transgender individuals. To institutionalize LGBTQ+ inclusive healthcare, health departments, healthcare centers, and pharmacies should develop manuals guiding the provision of friendly services. ¹¹ The Government of Nepal should take proactive measures, such as reserving medical seats to encourage inclusivity in medical education, fostering a healthcare system that respects and caters to the diverse needs of the LGBTQ+ community. Healthcare professionals can go beyond their clinical roles, providing support similar to that of family members for individuals experiencing exclusion. ⁷

Conclusion

This transformation of medical education is a critical step toward reducing healthcare disparities and ensuring that LGBTQ+ patients receive the same level of care, respect, and dignity as any other patient. By integrating LGBTQ+ health topics into the curriculum and promoting a culture of inclusivity, medical schools and institutions can produce healthcare providers who are not only knowledgeable but also compassionate and culturally competent in their practice. However, faculty development and training in LGBTQ+ health emerge as areas needing further study and enhancement to successfully deliver this content.