C. Teaching and learning about LGBT related health topics
One fifth of faculty reported using LGBT examples in class during teaching which featured under abnormalities/diseased states while over a third expressed interest in doing so. A quarter of the students had attended lectures where the following topics were mentioned: definition and theories of sexual orientation, HIV and sexually transmitted infections in LGBT people. The least addressed topics were homophobia, sex reassignment surgery and transitioning. The commonest teaching methods mentioned were tutorial, seminar and didactic lecture. [Table 3]
Ci - Current practice with regards to teaching and learning
Respondents believed that teaching and learning of LGBT topics in the classroom was inadequate. Faculty reported not teaching because it was either not relevant to their specialty or because it was not included in the current curriculum for teaching healthcare students in the institution. The students reported that LGBT topics were never directly addressed as the main focus of teaching, only occasionally mentioned in passing.
In the course of my practice, I do not see anything, that would take me into that and I don’t give lectures around cultural issues where we’ll be talking about stigma. I’ve never used it as an example in any of my lectures, so no, I have not had reason to talk about LGBT issues in any of my lectures. (F10)
I teach sexual dysfunction and paraphilias and that is why I have the opportunity of what, mentioning some of these things, okay, yes but it is not as if I’m going to teach them that because it’s just an overview in that curriculum and that is not enough. (F6)
Student’s descriptions of faculty demeanour while talking about LGBT topics in class ranged from professional, to verbal and non-verbal expression of discomfort. They expressed concern that some faculty were unable to teach the subject without introducing their cultural and religious beliefs. Despite the deficiency in the teaching, the content was considered useful.
She was showing a disgust in her facial expression, she was really angry like if she sees one of them right now she is going to fight the person that was her expression. I was uncomfortable at the beginning of the lecture but during the course of the lecture in my mind I was like me that I’m not even comfortable with it, I’m not as uncomfortable as she is…..why is she is so uncomfortable? (S1)
Cii - Concerns regarding teaching and learning about LGBT health topics within the culture of silence and a criminalizing law
Within the immediate physical and social environment, teaching and learning about LGBT topics in the classroom was considered unsafe. At the interpersonal level, students worry that their parent/guardian will object to their learning about the topics as well as the tone and the energy of the presentation. Faculty however were concerned about the ability to truly teach the topics in a professional manner devoid of beliefs and values while maintaining cultural sensitivity. Knowing that everyone listening to their lectures are trying to form an opinion on whether they are biased or in support of LGBT people is a psychological stressor for the few people who teach LGBT related health topics.
……So the onus is going to be on whoever or however the system is going to bring in teachings on LGBT health related topics...... it should be evidence based and knowledge based but you know very well that maybe at the point of the delivery, the beliefs and thoughts would come in, we should not deceive ourselves, it will come out there. (F1)
Some faculty noted that the unaccepting culture in the wider community influenced the institutional culture. The criminalising law strengthens this culture and makes it enforceable within the institution. For faculty the law generates concerns that it might be unsafe to teach LGBT topics in the classroom; this perception is borne out of interpersonal interactions between faculty as colleagues as well as faculty and students. This has negatively influenced the development and delivery of an inclusive curriculum.
……the teachers themselves come from a background where this was something that was not culturally, socially acceptable…..there are some people that deep down wouldn’t mind giving examples on LGBT health but they are afraid of the backlash. Once something is highly controversial like this, people are very careful. (F4)
The students also acknowledge that the decision to teach on these topics would not be straightforward and that there may be barriers:
First of all, before you can be able to teach, it has to pass through various processes, administrative and all that, so that can serve as a barrier at first, and I don’t know the orientation of people at the top about these issues too, they can also serve as barriers too, if you have the support of the management, it’s going to be easy, you know. (S10)
Ciii - Recommendations for effective training and integration of LGBT topics into the curriculum
In addition to the topics on ethics and professionalism which already exist in the curriculum, most of the participants supported teaching and learning within the institution using an inclusive curriculum. They suggested the development of innovative techniques and engaging methodologies for teaching LGBT topics in several departments within and outside the college supported by e-learning platforms and conferences.
D. Attitudes towards LGBT Patients
Faculty and students had divergent views on LGBT patients, with faculty expressing a higher level of acceptance than students (55.2% vs 41.9%). Respondents felt that healthcare professionals in public health facilities should treat LGBT patients, however, the majority would be wary about providing healthcare services. [Table 4]
Di. Conflicting heart, trying not to feel it, trying not to let it show within the context of service provision to a hidden population
Some respondents expressed difficulty in achieving a balance between professionalism and their beliefs. While some believe they will struggle with it, some believe that it is not a problem at all and others are convinced that the resulting conflict will negatively impact on their mental health. Providing general healthcare services constitutes an ethical dilemma while in other instances this will occur only with specialized services.
I do have strong beliefs but at the same time I believe that yes, they should have access to care, but I wish that our values are preserved and are not eroded because we want to provide healthcare, so that is where I have a bit of a problem with it. (F1)
Participants explored ways in which they might manage the negative effect on their mental health of this clash of their values and practice:
I think I will have negative attitude towards LGBT patient because I will always feel guilty, there’ll be a sense of guilt while treating them if I have to. I would rather not.… I hope I won’t have to take care of them but if I have to, it might affect my mental health but I will deal with it in the place of prayer and faith. (S4)
One interviewee felt that he would not be able to provide specific care to an LGBT individual and that if he was forced, he may leave the profession:
I will personally not be involved in converting a man to a woman. I will personally not, no matter the amount of money made available because it’s against my own religious and let me just say personal belief……if the law made it compulsory that I must do transgender surgery that I don’t believe in, then it will affect my mental state, I may even possibly resign. (F11)
Dii. Distrust and safety concerns surrounding healthcare professional and LGBT patient interaction
With regards to examination and clerking of LGBT patients, faculty were more comfortable than students. For students, the perception that an LGBT patient is dangerous plays a critical role in the level of comfort associated with providing care. Some students were scared of unwanted sexual advances/harassment. Intersection of identities and gender influences perception of danger
Providing physical care if the person is a em, female, like a lesbian, it will be at the back of my mind that oh! Hope she’s not showing some advances to me and all that, so I wouldn’t be comfortable at all. If it’s a gay man I wouldn’t be comfortable but at the back of my mind, I would be like oh! He does not really like females, so I can provide physical care to him I wouldn’t really see him as a threat [Smiling] Transgender! Ah! That one, I will not even know what to think, I think I will just find excuse and not care for the person or something. (S1)
Diii. Distrust and perception of rejection from healthcare provider
Some faculty were of the opinion that even though instances occur when healthcare professionals exhibit verbal and nonverbal acts of discrimination, LGBT patients have also been observed to be unduly sensitive during clinical encounters and biased against non-LGBT healthcare professionals. Thereby attributing the blame for poor and unsatisfactory patient-physician encounter on both parties i.e. the provider and the client.
……automatically you are just going to feel that oh! This person is doing a sinful thing and unconsciously you might just have that reservation against the act, you may not be against the people. Separate that okay somebody is uncomfortable with my sexual preference, not that the person hates me, not that the person wants to harm me. (F9)
I’ve treated quite a lot of them but there’s none of them that will not ask me, are you surprised doctor, some will say I see you didn’t even asked me further questions, some will say doctor, ah! Is it that you are not surprised, why do they ask such a question? That means they themselves have seen themselves as a different group from the norm of the community therefore it could be a perceptual disorder from them……… (F8)
Div. Access to healthcare services for LGBT people in Nigeria
Participants were of the opinion that the criminalizing law in Nigeria has negatively impacted on the willingness of healthcare professionals to learn about LGBT health related issues and service provision for them. This is mostly due to fear of LGBT people, fear of repercussion including courtesy stigma and arrest by law enforcement as well as lack of visibility of the LGBT population. Providers operate within the restriction and limitation of the law which, in effect, is preventing equal access to healthcare. The law also provides an escape route and justification for providers who may prefer not to interact with the population based on individual beliefs and values.
Some person may privately be trying to assist people and providing healthcare but I think it still goes back to the laws, the values and policies and in the absence of that, you know, you can not overtly assure those equal right, so you can mouth it, it’s just, it can be all talk but they are actually here to ensure that it’s not going to see the light of day. (F3)
….people don’t want to be associated with what is not openly accepted, meanwhile clandestinely they will provide that service, same thing nobody wants to be given the stigma that he or she treats or he or she manages someone who is lesbian, someone who is transgender or someone who is a gay, this carry stigma. (F5)
Dv. Recommendations for Healthcare professionals on service provision to LGBT people
Both faculty and students were of the opinion that a “holistic, comprehensive” (F10) approach to service provision is the best way to ease the stigma associated with LGBT identity and ensure that healthcare facilities become safe spaces for LGBT people
I don’t really know if you have a place where you label LGBT; nobody would want to go there because they know that okay, anybody that’s entering there, this is who you are, you are one of them. So, well, I just feel they should be treated like normal people, if you have any issues, just come around, I don’t feel there should be any segregation. (S10)
Nonetheless, the respondents acknowledged that in service provision, it would be difficult for healthcare professionals to overcome their personal prejudices and the stigma surrounding LGBT identity. At the institutional level, they identified the need to improve the quality of training for healthcare professionals as well as specially designed programs on ethics as the best option to help practitioners achieve professionalism in the presence of conflict.
……so maybe, they should start programs to help the people that are having problems, to help them to see LGBT people as human beings first and treat them as human beings and not as something...something...abominable or something. I think there should be programs created to help the doctors see the difference and maintain their professionalism. (S7)
Respondents considered some skills critical in other to provide culturally acceptable care to LGBT patients. These includes: friendliness, being knowledgeable about LGBT related health issues and responsive to patient/client needs.
…….the person might have a preconceived notion that they are going to stigmatize me and so they might read meaning into some things that should not be read meaning into, so em, health care workers too should have that at the back of their mind so that if the person is being defensive and all that, you just know that it maybe because of what they’ve experienced before or what they perceived…. (F9)
In addition, participants appealed to core professional values to explain how they could provide better care:
I think confidentiality should be of utmost importance in situations whereby you come across them because even within hospital settings, much as we like to pride ourselves on confidentiality, stories of patients with abnormalities always get out and so I feel like confidentiality should be formed that such information won’t. S6