Wednesday, August 10, 2005

Dare to CARE

August 9, 2005 12:00am
Source: Bangkok Post

Y utthachai Preeyamas feels comfortable with his sexual orientation, and is accepted by his family and friends as one of those Men Who Have Sex with Men, or MSM. But when the 27-year-old went to see a doctor with a rectal problem, he was surprised by the doctor's reaction.

"Instead of treating me professionally, the physician told me to quit being homosexual. He asked me why I couldn't love a woman. He also preached to me that anal sex was a channel for the HIV/Aids epidemic and recommended that I change my abnormal sexuality," he recalls.

Another MSM, Pornsak (not his real name), said he was frustrated when he went to the Red Cross to donate blood. On the application form, he was requested to state his sexual activities for safety purposes. "I felt uneasy when the nurse asked me if I was an MSM. I understood that the question was meant to check whether I was engaging in risky behaviour or not, but after all, isn't it mandatory to test all donated blood from everyone, whether straight or homosexual?"

A transgendered man, Nisarat (not her real name), also suffers from the same bias against homosexuality; she was not allowed to apply for private health insurance. "An insurance company rejected my application right away when they saw me. They said that, being a transgendered man, I have a high risk of HIV/Aids infection. But heterosexuals are as susceptible to HIV/Aids as homosexuals, aren't they?"

It can be even more troublesome for women who love women.

"Many avoid seeing doctors when it comes to problems with private parts because they feel uneasy being asked about their sexual behaviour. They usually end up finding pills at a drugstore, rather than seeking professional advice," says Nattaya Boonpakdee of the Women's Health Advocacy Foundation (WHAF).

Problems such as these were addressed at the 1st International Conference of Asian Queer Studies, held recently in Bangkok. Some 500 scholars, human rights activists, artists and film-makers convened to discuss, research and document Asian lesbian, gay, bisexual and transgendered (LGBT) cultures.

The conference examined how the quality of life for people with same-sex partners is affected by limited physical and psychosocial health care, a significant issue in the age of the HIV/Aids epidemic, widespread sexual transmitted diseases (STDs) and transgender operations.

"The attitude of health care providers is a critical factor in determining whether people with same-sex relationships can have access to quality health care," said Assoc Prof Peter Jackson, from the Australian National University in Canberra, a key organiser of the conference.

The growth of LGBT groups in Thailand, such as the Fa Si Roong (Rainbow Sky Association of Thailand, or RSA), the Bangkok Rainbow Group and M-Plus for gay men, plus Anjaree and Lesla for lesbians, has helped provide services to homosexuals in difficult situations by reducing the sense of isolation and providing support.

"The [health] services are much needed but still inadequate. Mainstream social programmes and public attitudes toward queers as deviants and pitiful people still loom large," said Viroj Tangvanich, president of RSA, the first and only gay organisation registered with the Office of the National Culture Commission in Thailand.

Participants at the conference emphasised differences amongst the three main groups of LGBTs when it comes to health issues:

MSM (Men Who Have Sex with Men)

Risky sexual behaviour is a major concern among MSM groups. But in the on-going battle with HIV/Aids, STDs, hepatitis, rectal cancers and, increasingly, anal warts (anal condyloma acuminate), MSMs in Thailand still have to fight sexual bias caused by the limited availability of professional services, equipment and well-trained public health personnel, says Rapepun Jommaroeng from RSA.

"There was a case in which a doctor asked a patient, 'Why does it hurt when I insert the probe? Isn't anal sex more painful?' He lacks the sensitivity needed for MSM treatment," Rapepun says.

He adds that many times the focus is on sex-related diseases only, with basic health issues overlooked "Heavy alcohol consumption and smoking are rarely mentioned as health threats among MSM. Insomnia and restlessness have also become prevalent among the group. But few studies pay attention to these issues," he says.

Besides, the group also suffers psychological problems, mainly stress, in family, school and work situations. There is also the problem of self-acceptance.

"While struggling to understand themselves, some homosexuals can't function well at school _ they're afraid their peers and teachers will not accept their sexual preference. In some conservative families, gay teens can be kicked out of the house and become homeless or even criminal," he says.

"Most gay men do not have role models that would help them develop their identity more confidently. And general meeting spaces are also limited to gay areas, such as Silom sois 2 and 4, public parks and saunas, which is not the best way to learn about oneself," he adds.

Another problem lies in the inter-ministerial conflict of government policy towards gay health and lifestyles. "While the Ministry of Health promotes the use of condoms in saunas, the Ministry of the Interior raids saunas and regards used condoms found there as evidence of prostitution."

Transgendered/Transsexual/Transvestite (TGs)

TGs, or katoey in Thai, are increasingly common in Thailand, but their growing numbers have not led to an increase in the sort of information and specialist health services that they require.

"Many TGs believe that they are women trapped in the bodies of men, and to be able to find true love, mostly with straight men, they have to transform themselves into women. That's why sex change surgery tends to become their ultimate goal," says Pornthep Prae-kao, a PhD candidate at Khon Kaen University's Nursing School.

Sex change surgery comes at a cost: many trade their physical health for psychological happiness and self-esteem.

"After the removal of the testicles, the body cannot produce male hormones, so patients have to rely heavily on hormone tablets to maintain an equilibrium in their body chemicals for the rest of their lives."

But such drugs are not without side effects, which include nausea, dizziness and premature ageing. Some have to change hormones constantly to find ones that will work properly, a process that causes both physical pain and psychological frustration.

"If they stop taking hormone pills, the skin can become rough and start ageing faster, making them look older than they really are. Many stop seeking their doctors' advice because of the expense and instead rely on advice from friends about new treatments."

Without continuous professional care, many will also experience other health problems such as permanent fatigue, constant pain in their new sexual organs, incontinence and loss of sexual desire.

"One 21-year-old TG man said she had no idea why she did it [the operation] in the first place. She felt it was normal for TG men to have a sex-change operation, but later she questioned herself as to why she had to make herself a sick woman, when she could have been physically healthy as a man," Pornthep says.

To have a female voice, many undergo laser operations on the vocal cords, or a paring down of the Adam's apple, which carries a 50 percent risk of causing muteness.

"But many take the risk to become real women," Pornthep adds.

Some TGs will never gain acceptance from their families and communities, especially as they grow older.

Without public acceptance of their individual choices, many become the subject of constant mockery. Some even attempt suicide.

"I know one TG who decided to remove her artificial breasts while she was in her early forties. She didn't want her younger relatives to regard her as a weirdo. It was a traumatic decision for her but she wanted to be normal in their eyes," he recalls.

While many TGs work as cabaret performers, female impersonators and make-up artists, some, especially those who have poor education and have run away from home, end up as sex workers. Without proper health services, they fall victim to STDs and HIV/Aids.

"Some clients avoid using condoms with TGs as they assume that TGs are not really prostitutes, and many TGs consent in order to please their clients. Many are under the influence of drugs and alcohol when they have unprotected sex," says Sitthiphan Boonyapisompan, supervisor of the Outreach programme at Population Services International (PSI) Asia, which was established to provide support to TGs in Pattaya.

When they are arrested for lewd conduct, the legal procedures _ such as whether to treat them as men, women or TGs _ are not always clear-cut and transparent, Sitthiphan says. This also applies to charges of rape. Male-to-female TGs can only file an indecency charge (anacharn in Thai) but not a criminal charge, as they are not recognised as women either physically or legally.

"For TGs, there should be a referral system to fair, legal and effective health care services," he suggests.

Women Who Love Women

Perhaps most marginalised in terms of health care services are women who love women. According to Nattaya Boonpakdee from WHAF, many find it difficult to obtain information about safe sex, which is heavily skewed toward gays and TGs. The general public mostly regard sex between women as safe, since it is assumed that no penetration is involved.

"But there are other practices that can lead to STDs or HIV/Aids infection, and many women still haven't learned about safe sex. Only few have access to sex education, which is mostly in English on web sites," she points out.

She adds that the incidence of HIV infection among the group is steadily increasing because some women have been infected by former partners _ male or female _ and unknowingly transfer the infection to new partners. Many have no idea that oral sex and sex toys can be risky, too.

"To avoid discrimination by physicians, many lie to their doctor about their sexual behaviour or rely on the advice of friends. The chances of permanent healing and well-being are not guaranteed," Nattaya notes.

Prof Dr Suporn Koedsawang, who wrote a book about MSM health, adds that like many single women, lesbians are susceptible to a range of physical problems, including endometriosis, breast cancer and ovarian cancer.

"But only few researchers address these health problems among this group. With more knowledge made available to the group, we could help them learn how to take good care of themselves before it's too late," he says.

A ccording to experts in the field, the health of homosexuals can be improved in four major areas: Better understanding and more informed attitudes toward homosexuals within the medical profession; better health services and schemes for the group; an adequate and accessible body of knowledge on health issues and social adjustment; and fair policy and planning from the government.

"Medical professionals need more than knowledge and skill for treatment. They must understand people's rights and overcome their biases and ignorance about the LGBT group," says Krittiya Archawanitkul, a human rights expert from Mahidol University.

But changing perceptions takes a long time. "We can view LGBTs as a sexual minority group. But that should not rule out their right to standard services and professional treatment. With some sensitivity, their rights would be less easily violated," she says.

To tackle the high rate of new HIV infections and other STDs, Bang Rak Hospital on Sathon Road has opened a special clinic for MSM and male sex workers. But they can only accommodate 20 patients a day.

"We need more venues for treatment and more specially-trained personnel who understand the LGBT lifestyles and won't blame the patients' sexuality or gender for their problems. These experts can address both the physical and psychological aspects of their patients," adds Nattaya.

"But to label the clinic as LGBT, MSM, TG or Women Who Love Women is also a sensitive issue. Many gay men and women might still be in the closet and are not comfortable walking into such a clinic for fear of public ostracism," adds Rapepun.

More studies should explore the medical and psychosocial problems of queers. This includes work on the consequences of sex changes, individuals' sexual/gender identity, and public reaction towards homosexuals in Thai society. And it is important to make the resulting information more easily accessible to the group.

"Currently we rely on material from the Internet, which is mostly written in English. Some Thais find it hard to understand the technical language. But most crucially, one should be very careful about information found online, as it is often full of inaccuracies, misconceptions and myths about LGBT health," warns Nattaya.

Most significantly, public health policy should acknowledge the need for health services among the LGBT group.

"For example, the Public Health Ministry's 30 baht universal health care scheme does not have a package for TG men. Shouldn't they be tested under women's yearly check-up?" asks Pornthep.

"Everyone in this country is entitled to good health, and the LGBT group deserves better health services than they are receiving. After all, they are taxpayers too," says Krittiya.

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