Barriers in Access to Health Care Services among Lesbian, Gay, Bisexual, Transgender (LGBT)

Abstract

Health is one of the fundamental rights of every human being without distinction on any basis. Yet,the Lesbian, Gay, Bisexual, and Transgender population still suffer from prejudice and discrimination in access and use of these services which place disparities in health status between sexual- and gender-minority and heterosexual individuals. The purpose of this Descriptive cross-sectional study was to assess the barriers in access to health care services among the Lesbian, Gay, Bisexual, and Transgender(LGBT)individuals within the Kathmandu Valley using Semi-structured questionnaires. This study was conducted among 87 LGBT participants including 49.9% Cisgender, 50.6% Transgender,50.6%heterosexual, 46% homosexual, and 3.4% bisexual individuals.Only 28.7%of them faced physical barriers i.e.,toilet 76% and registration forms 76%, changing room 36%, wards 24%, gender binary queues 20%, and Age of <21(p=0.035)and Homosexual group (p=0.021) statistically significant with behavioral barriers. However, Age of group >38(p=0.001), respondent with secondary level (p=0.005)and socially open about own sexual orientation and gender identity associated with Psychological barriers.

Full text

International Journal of New Technology and Research (IJNTR)
ISSN:2454-4116, Volume-5, Issue-3, March 2019 Pages 15-20
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
Abstract—Health is one of the fundamental rights of
every human being without distinction on any basis.
Yet,the Lesbian, Gay, Bisexual, and Transgender
population still suffer from prejudice and
discrimination in access and use of these serviceswhich
place disparities in health status between sexual- and
gender-minority and heterosexual individuals. The
purpose of this Descriptive cross-sectional study was to
assess the barriers in access to health care services
among the Lesbian, Gay, Bisexual, and Transgender
(LGBT) individuals within the Kathmandu Valley
using Semi-structured questionnaires. This study was
conducted among 87 LGBT participants including
49.9% Cisgender, 50.6% Transgender,50.6%
heterosexual, 46% homosexual, and 3.4% bisexual
individuals. Only28.7% of them faced physical
barriersi.e.,toilet 76% and registration forms 76%,
changing room 36%, wards 24%, gender binary queues
20%, and Age of <21 (p=0.035)and Homosexual group
(p=0.021) statistically significant with behavioral
barriers. However, Age of group >38(p=0.001),
respondent with secondary level (p=0.005) and socially
open about own sexual orientation and gender identity
associated with Psychological barriers.
Index Terms—Access, Barriers, Health care services,
LGBT
I. INTRODUCTION
Lesbian, gay, bisexual, and transgender (LGBT) is an
umbrella term, which includes a number of groups: lesbian,
gay, bisexual, transgender, queer, questioning, intersex,
asexual, allies, two spirits, and pansexual.About 3.5%
Americans identify themselves aslesbian, gay, or bisexual
while 0.3% identify themselves as transgender [1].
Priya DarshaniGiri, Purbanchal University/ Asian College for Advance
Studies, Kathmandu, Nepal
Anup Adhikari, General Secretory, Nepal Family Development
Foundation, Lalitpur, Nepal
Mamata Praadhan, Department of Nursing, Purbanchal University/
Asian College for Advance Studies ,Kathmandu, Nepal
Ishu Yogi, Department of Nursing, Purbanchal University/ Asian College
for Advance Studies, Kathmandu, Nepal
Sudip Khanal, Academician and Statistician, Kathmandu
The facts regarding the situation of LGBT in Nepal are rare;
however, there are estimated to be more than 4000,000
people who belong to sexual and gender minorities [2] in
Nepal. According to The Williams Institute/BDS survey
2013 done among 1,178 participants from 32 out of 75
districts of Nepal, there were 64.5% transgender female,
7.1% transgender males, 22.1% people were considered as
male at birth who identified as gay/bisexual and6.4%
people were assigned female role at birth thatlater identified
as lesbian/bisexual [3].
The LGBT community is diverse. What binds them
together as social and gender minorities are common
experiences of stigma and discrimination, with respect to
health care, a long history of discrimination and lack of
awareness of health needs by health professionals [ 4].
Currently, in Nepal, there is a lack of understanding of
health and well-being, social exclusion, stigma, and
discrimination as experienced by these populations [5].
“The enjoyment of the highest attainable standard of
health is one of the fundamental rights of every
human being without distinction of race, religion,
political belief, economic or social condition”[6].
Yet, there are various factors that prevent an individual
from gaining access to health, social care and early year
services[7], such as High cost of care, Lack of availability
of services, Lack of infrastructure, inadequate resources
and health workers’ motivation[8], financial barriers,
discrimination, lack of cultural competence by providers,
health systems barriers and socioeconomic barriers[9].
While sexual and gender minorities have many of the same
health concerns as the general population, the LGBT
population exceptionally face stigma, discrimination, the
provision of substandard care, outright denial of care
because of an individual’s sexual orientation or gender
identity[3,10] reluctance to Disclose Gender Identity, and
Other Barriers (Health insurances)[11].
This study was carried out using semi-structured
questionnaire through interview method to assess the
physical, behavioral and psychological barriers in access to
health care services among Lesbian, Gay, Bisexual and
Transgender (LGBT) individuals who are currently
working in the Blue Diamond Society and its associated
organizations within the Kathmandu Valley.
Barriers in Access to Health Care Services
among Lesbian, Gay, Bisexual, Transgender
(LGBT)
Priya Darshani Giri, Anup Adhikari, Mamata Pradhan, Ishu Yogi, Sudip Khanal

Barriers in Access to Health Care Services among Lesbian, Gay, Bisexual, Transgender (LGBT)
16 www.ijntr.org
II. METHODOLOGY
A descriptive cross-sectional study was conducted over the
months of June- July 2018 among theLGBT
individualswithin Kathmandu Valley. The study included a
total of 87 LGBT participants who are currently working in
the LGBT organizations within the valley namely
Federation of Sexual & Gender Minorities –Nepal
(FSGMN), Blue Diamond Society, ParichayaSamaj,
Cruise aids, Pink Triangle Nepal, Our Equal Access and
Care Nepal. Census was carried out in the purposively
selected organizations. Data was collected through
predesigned, pre-tested semi-structured questionnaire
through interview.
Research instrument was developed after literature review,
consultation with supervisors and subject experts from the
FSGMN student forum. Pretesting of the developed tool
was done in ParichayaSamaj, Sanepa, Lalitpur and
necessary modifications were made to assess the
understanding and accuracy of test instrument.
The internal consistency of the Likert scales for behavioral
and psychological barriers was tested by calculating
Cronbach alpha in SPSS version 22. The obtained value
was Cronbach alpha 0.947 which was in excellent range.
So, all the developed research instruments were used for
data collection. Study was conducted after the approval of
research committee of Asian college for Advance Studies
(ACAS). Similarly, an official letter was submitted to Blue
Diamond Society (BDS) regarding this research work.
Consent was taken from participants prior to the study.
LGBT individuals who were not available at the time of
data collection were excluded. Collected data was entered
into Epi-data software and then transferred to Statistical
Package for Social Sciences (SPSS)version 22. Descriptive
statistics like frequency, mean,standarddeviation,
percentage andKruskal Wallis test and Mann-Whitney U
test were used for analysis.
III. FINDINGS
This study comprised 87 participants including 75 (86.2%)
biologically born male and 12(13.8%) biologically born
female, mostly (70%) from the age group 21 to 38 years of
age (mean 29.61+8.55).The study had 35(40.2%)
transgender females and 9(10.3%) transgender males,
40(46.0%) homosexuals and 3(3.4%) bisexual participants.
However, 56 (64.4%) among the total participants reported
to be socially open about their sexual orientation and
gender identity and 31(35.6%) of them are yet to come out.
Total 28(32.2%) had completed secondary level education
while only 6(6.9%) of them were illiterate. (SeeTableI)
Table I. Demographic information of participants
Variables(N=87)
Frequency
Percent
Age in Years
< 21
10
11.5
21-38
63
72.5
> 38
14
16.1
Mean Age + SD (29.6+8.5)
Sex
Male
75
86.2
Female
12
13.8
Gender identity
Cisgender male
40
46.0
Cisgender female
3
3.4
Transgender male
9
10.3
Transgender female
35
40.2
Sexual orientation
Heterosexual
44
50.6
Homosexual
40
46.0
Bisexual
3
3.4
Socially open about own sexual orientation and gender
identity
Yes
56
64.4
No
31
35.6
Level of education
Illiterate
6
6.9
Primary
12
13.8
Secondary
28
32.2
Higher secondary
27
31.0
Bachelors and higher
14
16.1
Table II shows that out of 87 participants, only 28.7%
participants faced problems due the physical setting of the
health care centers. Most of the problems faced were due to
lack of LGBT- friendly settings such as registration forms
(76%), toilets (76%), changing rooms (36%), wards (24%),
arrangement of separated queues of either male or female
(20%), and procedure rooms (5.3%).
Table II. Physical barriersin access to health care services
Variables
Frequency
Percent
Problems faced
25
28.7
Problems not faced
62
71.3
If yes, types of problems
faced*
lack of LGBT-friendly
registration forms
19
76
lack of LGBT-friendly toilets
19
76
Separated arrangement of
only male and female queues
19
76
Problems due to lack of
LGBT-friendly changing
rooms
9
36
Problems due to lack of
LGBT-friendly wards
6
24
Problems due to lack of
LGBT friendly procedure
rooms
1
5.3
*Multiple responses
Out of 87 participants, 58 (66.7%) participantsadmitted
that the health care personnel were friendly and are
communicated properly (68.9%) and showed respect
towards them (66.7%). Moreover to it, 62 (71.3%) of the
participants accepted that the health care personnel were
sensitivetowards their health needs, kept their sexualand
gender status confidential (57.4%) and accepted to provide
care to them regardless of their sexual and gender identity
(75.8%). (SeeTable III)

International Journal of New Technology and Research (IJNTR)
ISSN:2454-4116, Volume-5, Issue-3, March 2019 Pages 15-20
17 www.ijntr.org
Table III. Behavior of Health workers as barriers in
access to health care services
Statements
SA
%
A
%
N
%
D
%
SD
%
Health personnel are friendly to me
4.6
62.1
18.4
12.6
2.3
Health personnel communicate
properly to me
8.0
60.9
14.9
14.9
1.1
Health personnel show respect towards
me
9.2
57.5
14.9
18.4
0.0
Health personnel are sensitive towards
my health needs
6.9
64.4
8.0
17.2
3.4
Health personnel accept to provide care
to me
12.6
63.2
12.6
11.5
0.0
Health personnel have kept my sexual
and gender status confidential
14.9
42.5
19.5
16.1
6.9
Health personnel have not
discriminated me in providing health
care services
11.5
55.2
13.8
14.9
4.6
Health personnel have not blamed me
about me sexual and gender identity
16.1
48.3
17.2
13.8
4.6
Health personnel have not denied
admitting me to the hospital
19.5
64.4
5.7
9.2
1.1
Health personnel have not done any
verbal harassment to me
16.1
52.9
9.2
16.1
5.7
SA= Strongly Agree, A= Agree, N= Neutral, D= Disagree,
SD= Strongly Agree
Out of total participants, 47.1% of the participants
wereembarrassed and unwilling to disclose their sexual and
gender identity, ( 58.6%) participants fear of being
discriminated, blamed ( 46%,), verbally harassed
(62.1%),misbehaved ( 39.1%), and had bad experiences
(37.9%) at health care settings due to their gender identity
and sexual orientation.
Table IV. Psychological barriersin access to health care
services
Statements
SA
(%)
A
(%)
N
(%)
D
(%)
SD
(%)
Embarrassed to disclose my
sexual and gender identity
11.5
35.6
8.0
24.1
20.7
Unwilling to disclose sexual and
gender identity
9.2
37.9
4.6
37.9
10.3
Fear of discrimination due to
sexual and gender identity
16.1
42.5
11.5
24.1
5.7
Fear to be blamed about sexual
and gender identity
11.5
34.5
13.8
36.8
3.4
Fear of being verbally harassed
due to sexual and gender identity
16.1
46.0
8.0
26.4
3.4
Fear of being misbehaved due to
sexual and gender identity
6.9
32.2
17.2
37.9
5.7
Feel uncomfortable to share
health problems
9.2
35.6
5.7
40.2
9.2
Doubt of confidentiality about
sexual and gender identity
10.3
31.0
26.4
25.3
6.9
Feel that HC professionals are
unable to understand health
issues
9.2
33.3
12.6
42.5
2.3
Had bad experiences related to
sexual and gender identity at
health care centers
11.5
26.4
5.7
40.2
16.1
SA= Strongly Agree, A= Agree, N= Neutral, D= Disagree, SD=
Strongly Agree
A total of 42.5% participants felt that health care
professionals are unable to understand their health issues,
and44.8% felt uncomfortable to share health problems and
only 41.3% of them doubt that their sexual and gender
identity would be kept confidential. (See Table IV).
Table V. Association between socio-demographic
variables and behavioral barriers
Kruskal Wallis Test
Factors
Median
H
Df
p
Age in years
6.71
2
<21
59.4
0.035*
21-38
44.4
>38
33.6
Gender identity
6.12
3
Cisgender male
50.5
0.107
Cisgender female
50.2
Transgender male
32.3
Transgender
female
39.1
Sexual orientation
7.68
2
Heterosexual
37.7
Homosexual
48.9
0.021*
Bisexual
70.7
Level of education
3.47
Illiterate
53.1
Primary
51.9
Secondary
39.0
0.481
Higher secondary
45.6
Bachelors and
higher
40.3
Mann-Whitney U Test
Median
U
Sex
363.5
0.284
Male
45.2
Female
36.8
Socially open about own sexual
orientation and gender identity
853.5
Yes
43.7
0.897
No
44.5
* Significant at 5%
The table V shows that Behavioral barrier is strongly
associated with age groups of < 21 years (p=0.035) and
sexual orientation at homosexual group (p=0.021).
However, Behavioral barrier is not statistically significant
with gender identity, level of education, biological sex and
socially open about own sexual orientation and gender
identity.
Table VI.Association between sociodemographic
variables and psychological barriers
Kruskal Wallis Test
Factors
Median
H
df
p
Age in years
17.78
2
<21
53.6
21-38
48.3
>38
23.2
0.001*
Gender identity
5.59
3
Cisgender male
49.2
0.134

Barriers in Access to Health Care Services among Lesbian, Gay, Bisexual, Transgender (LGBT)
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Cisgender female
18.2
Transgender male
44.1
Transgender female
40.3
Sexual orientation
2.45
2
Heterosexual
41.1
Homosexual
45.8
0.294
Bisexual
62.7
Level of education
14.97
Illiterate
27.3
Primary
31.8
Secondary
37.1
0.005*
Higher secondary
55.3
Bachelors and higher
53.5
Mann-Whitney U Test
Median
U
Sex
373.5
Male
45.0
0.346
Female
37.6
Socially open about own sexual
orientation and gender identity
853.5
Yes
49.3
0.009*
No
34.5
* significant at 5%
The table VI shows that psychological barrier is strongly
significant with age group of >38 years (p=0.001) and level
of education with higher secondary (p=0.005). Moreover,
socially open about own sexual orientation and gender
identity(p=0.009). However, psychological barrier was not
associated with gender identity,sexual orientation and
biological sex.
IV. DISCUSSION
The socio demographic information of the current study
showed that that out of 87 participants, more than 70% of
them were from the age group 21 to 38 years of age. The
mean age of the participants was 29.6years. Similar finding
is found in a recent cross sectional study in Nepal
conducted among 232 Male to Female(MtF) transgender
persons shows that the median age of the participants was
25 years and most of the respondents (56.5%) were aged 25
years and above[12]. Nearly half (49.4%) of the
participants were Cisgender while 50.6% of them identify
themselves as Transgender individuals. Likewise, half of
the total participants (50.6%) were heterosexual, and 46
percent of them report their sexual orientation to be
homosexual and only few (3.4%) of the participants say
that they are. Bisexual. In another similar study about 3.5%
Americans identify themselves as lesbian, gay, or bisexual
while 0.3% identify themselves as transgender [ 1].
Regarding the status of coming out, the study findings show
that more than half (64.4%) among the total participants
reported to have come out about their sexual orientation and
gender identity in the society and friends. However, more
than one fourth (35.6%) of them are yet to come out. The
study findings also indicates that most of the
participantshad completedsecondary (32.2 %) and higher
secondary (31%) level of education. As stated in a report
on the Nepal National LGBTI Community Dialogue held in
Kathmandu in April 2014, Some LGBT students dropped
out of school due to bullying and harassment [4]. In the
study of 232 transgender females in Nepal, more than half
(57.3%) of the total sample had a secondary or higher level
of education [12].
The types of physical barriers identified in the study are
problems due to physical setting of the health facility
mainly barriers due to lack of LGBT- friendly registration
forms (76%), toilets (76%) and the system of arrangement
of queues in either male of female (20%) which causes
problems to these individuals while accessing the health
care service center. Similarly, nearly half (47.4%) of the
problems faced by the LGBT individuals was due to lack of
LGBT friendly changing rooms. Similar findings are found
in a qualitative study among Lesbians of Nepal,
theparticipants commonly reported that it is difficult to
make an appointment with the doctors because the
disclosure of male or female identity is required in most
cases. In addition, they also argued that they did not find it
comfortable to be in a male or female ward. It has often
made it difficult for them to decide whether to get admitted
or not [13].
Similarly, behavior of health care provider was also
identified as the barriers in access to health care. A total of
63.2% participants experienced lowlevels of behavioral
barriers in access to health care services. Significant
associations were also seen between theparticipants’ age,
sexual orientation, gender identity with how the health care
providers behave with the client from sexual and gender
minority group. The study conducted by Williams
Institute/BDS across 32 districts of the country also
presents that over 60 percent of the participants reported
experiencing at least one incident related to verbal
harassment, physical abuse and denial of service in health
care settings [3]. Similar kind of finding was also seen in
the report of the National Transgender Discrimination
Survey of transgender individuals. It was found that 19%
of the sample reported being refused medical care due to
their transgender or gender non-conforming status. Survey
participants also reported that when they were sick or
injured, many postponed medical care due to discrimination
(28%) or inability to afford it (48%) which clearly
indicates discrimination in health care and poor health
outcomes [14]. Systematic review conducted using
PubMed, Cochrane, SciELO, and LILACS, considering the
period from 2004 to 2014 reveals that the homosexual

International Journal of New Technology and Research (IJNTR)
ISSN:2454-4116, Volume-5, Issue-3, March 2019 Pages 15-20
19 www.ijntr.org
population have difficulties of access to health services as a
result of heteronormative attitudes imposed by health
professionals [15].
Apart from the physical and behavioral barriers,
psychological barriers also play vital role in access to health
care among LGBT population. The psychological barriers
were found to be high in 52.9% study participants out of
87. Study participantsexperienced ahigh level of
psychological barrier. The study findings reveal that 10 out
of 87 of the study participants confessed that they did not go
for regular health checkups due to the fear of being
misbehaved by the health care personnel. About 60%of the
participants stated ‘experience of fear of being misbehaved
by health care staff’ as the main reason for postponing their
health care treatment. Similarly, 42.5% agreed that they
had fear of being discriminated on the basis of their sexual
orientation and gender identity. As a result, LGB persons’
previous negative experiences with the health care system
or perceptions of discrimination in the system may cause
them to delay seeking health care [16].
ACKNOWLEDGMENTS
We thank all the study participants who have contributed to
this study.We are also grateful to Asian college for advance
studies, the Federation of Sexual & Gender Minorities
–Nepal (FSGMN), Blue Diamond Society, ParichayaSamaj,
Cruise aids, Pink Triangle Nepal, Our Equal Access and
Care Nepal. Similarly,our vote of thanks goes to Nepal
Family Development Foundationfor support in data
management, analysis and interpretation and report writing.
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Priya DarshaniGiri is a student of Bachelor in
Public Health at Asian College for advance studies,
Purbanchal University, Nepal.
Anup Adhikari isa General secretory of Nepal
Family Development Foundation (NFDF). He had
completed master’s degree in population studies
from Central Department of Population Studies. He
had published many research articles in national and
international journals. He had more than8 years of
research-based project and working experience in Data management and
analysis by using various statistical software. Currently he is working on
TyVAC project as a team leader and Editor at yaunik.com online
magazine.
Mamata Pradhanisworking as Co-ordinator at
Asian College for Advance Studies, Satdobato,
Lalitpur. She had completed her Bachelor Degree in
Nursing from TUIOM Lalitpur Nursing Campus,
Sanepa, and Master Degree in Public Health from
Sam Higginbottom Institute of Agriculture,
Technology& Sciences Aallahabad, India. She has
more than 15 years’ experience in Clinical Nursing
and academic.

Barriers in Access to Health Care Services among Lesbian, Gay, Bisexual, Transgender (LGBT)
20 www.ijntr.org
Ishu Yogiis working as Lecturer at Asian College
for Advance Studies, Satdobato, Lalitpur. She had
completed Masters in Nursing (MN) in Advance
Adult Nursing from T.U.I.O.M
Sudip Khanalis working as a Statistician and
Academician. He hadcompleted Msc.Statistics
from Central Department of Statistics. He had
more then 10 years of teaching and more than 2
years working experience in Data management
and analysis by using various statistical software.
Currently he is working in Nepal Family
development Foundation as a trainer on Data
management and Analysis.