When medical professionalism and culture or the law collide: Gay patients in homophobic societies

Medical professionalism faces serious challenges in homophobic societies. A case in point: Uganda. The country has gained global notoriety for having implemented one of the toughest anti-LGBTQ laws in the world. It includes the death penalty for something called ‘aggravated homosexuality’, as well as a 20-year prison sentence for ‘promoting’ homosexuality.1

When issuing a different, less draconian anti-gay legislation some years back, the country's health minister assured Ugandans, as well as the international community, that all people, regardless of sexual orientation, would receive ‘full treatment’ and added that ‘health workers will live up to their ethics of keeping confidentiality of their patients’.2 Gay patients experienced a quite different reality. In 2017 the activist group Sexual Minorities Uganda issued a report under the title ‘Even if they spit at you, don't be surprised’.3 I recommend the document to your attention. It's replete with first-person accounts of unprofessional conduct by health care professionals. It ranges from the use of derogatory language to refusal of service provision to actual physical attacks. There is also evidence of medical school training containing scientific misinformation on homosexuality.

While unusual by today's global standards, Uganda isn't the only country with anti-gay legislation on its books. Less draconian legislation can be found in homophobic societies like Jamaica, for instance. There is a high number of former British colonies with such laws, but it's unclear whether that's mere correlation or whether there is a causation-type relationship. While the legislation in place oftentimes is a relic of colonial era laws, there also appears to be widespread societal support for such measures in these predominantly Christian societies. While some Caribbean nations have recently decriminalized consensual same-sex relations, six Caribbean countries, among them larger countries like Jamaica, still criminalise consensual same-sex sexual relations. They are not alone, some 66 countries reportedly criminalise consensual same-sex relations.4 The World Medical Association saw it fit, against this background, to issue a strong statement condemning the participation of medical professionals in anal examinations ostensibly designed to assist in determinations of same-sex sexual activities.5 Apparently such examinations actually happen in certain societies, even though they are based on humbug science.6

This raises a number of important issues regarding the health care that patients who identify as gay or queer, or who participate in same-sex sexual relations, can reasonably expect in such societies. The uncontroversial objective of health care provision is to increase or maximise the number of life-years a person can live with a good quality of life that makes their life worth living, in their own considered judgment. Health care professionals value judgments about the lifestyles that patients live should not affect the care that they receive; anything else would arguably constitute unprofessional conduct, because of the likely negatively impacts on the delivery of health care.7

Incidentally, this isn't a statement that is merely true vis-à-vis queer patients, it is true for all patients. Overweight patients, for instance, have long complained about the effects of weight discrimination in health care settings, and the harmful impacts of that discrimination on the quality of the health care that they received.8 Similar issues arise with regard to ‘difficult patients’.9 Implicit biases of health care professionals have been shown to increase health disparities.10 Among the obvious solution is sensitivity-training, where it is assumed that healthcare professionals, when made aware of their biases, will want to proactively monitor themselves to ensure that their biases don't affect the health care that they deliver. Of course, if the biases of health care professionals in Uganda trigger them to physically attack queer patients, one has to wonder about the chances that such training will greatly impact on professional conduct, but it probably is worth trying. Another measure a responsive health care system can implement is to increase the number of professionals from those groups that are negatively affected by implicit biases.

Obviously, if any, only the first of these solutions has a chance of success in the Ugandas of the world. Authorities need to ensure, no matter their disdain for queer people, that health care is attainable to such patients. It is also the responsibility of, for instance, the Uganda Medical Association to ensure the professional conduct of its members. On its website is pronounces that it promotes ‘the highest possible standards of medical ethics and provides ethical guidance to doctors.’ Its Vision is that: ‘All the people in Uganda have access to quality health and health care’.11 That most certainly includes queer Ugandan patients then. As it happens, the Uganda Medical Association is also a constituent member of the World Medical Association. The World Medical Association has publicly condemned the Ugandan anti-gay legislation and called on its constituent members to do the same.12 Medical professionalism and professionals’ bias against queer patients are incompatible. Those who discriminate against sexual minorities tend to gesture today toward respect for cultural diversity as a justification for their human rights violating conduct, but that won't do in the case under consideration, because patients see professionals in their professional roles, not as private citizens. Professional values dictate the proper conduct during professional consultations, not idiosyncratic personal values, no matter how prevalent they might be in society. It's incumbent upon professional associations to follow through on the promises they make to society, and discipline those of their members who fall short of what is professionally required of them. Bias, culture, even discriminatory laws cannot justify the delivery of suboptimal health care that results from the personal prejudices of professionals, even if those prejudices are widely shared in their particular culture.