Kolkata, August 4, 2018: “With only 3,827 government and private sector psychiatrists registered with the government in India (one per roughly four lakh population), how can we think about ensuring quality mental health services to people?” – Shampa Sengupta, Kolkata-based disability rights activist (she was referring to data provided by the Ministry of Health & Family Welfare, Government of India in response to a question raised in the Lok Sabha recently).
“I would say queer students in India are pushed out of schools and colleges rather than them dropping out!” – Rituparna Borah, Delhi-based queer feminist activist, who advocates on gender and sexuality issues with educational institutions.
“Queer adolescents in rural areas face many barriers when it comes to expressing any concern around their gender or sexuality and have few options in terms of accessing mental health professionals” – Mohit Ranadip, psychiatric social worker from Serampore, who works with young people from diverse socio-economic backgrounds in West Bengal.
“How do we ensure that mental health services reach transgender people in the remotest areas of West Bengal?” – Sudipa Chakraborty, transgender healthcare activist associated with SAATHII, an NGO working on universal access to health and social justice for communities marginalized on grounds of HIV, gender and sexuality.
A sample of quotes from speakers and the audience at a recent symposium on mental health concerns of queer people organized in Kolkata. These individuals were among 30-35 mental health professionals, students, academics, researchers, lawyers, healthcare workers, queer activists, and queer community members participating in the symposium called ‘Queering Mental Health’ (see inset). The symposium discussed and debated the mental health concerns of queer people in India, and how these concerns could be better addressed.
Disproportionate burden of mental health problems on queer people
For Varta, ‘mental health’ and ‘mental health concerns of queer people’ are two areas that have been of specific interest right from its inception on August 1, 2013. Worldwide statistics show that queer people are more likely to face mental health problems because of stigma, discrimination and violence around their genders and sexualities. In their paper Homosexuality and India (published in Indian Journal of Psychiatry, January-March 2012), mental health professionals T. S. Sathyanarayana Rao and K. S. Jacob say, “People with homosexual orientation face many hurdles including the conflicts in acknowledging their homosexual feelings, the meaning of disclosure and the problems faced in coming out.”
The Guardian newspaper in UK published a similar article in May 2017. Titled LGBT People Are Prone to Mental Illness. It’s a Truth We Shouldn’t Shy Away From, the article reported data from a 2015 study conducted by the Centers for Diseases Control, USA. The study revealed that queer teenagers were more than four times likely to commit suicide than other teenagers. The article also pointed out that 86 percent of the staff of Stonewall, a queer health support forum, had experienced mental health issues first hand.
Another article Mental Health, written by Hannah Ritchie and Max Roser and published in Our World in Data in April 2018, provides analysis on the links between specific mental health problems and suicide the world over. It lists a number of adverse social circumstances as a risk factor for mental ill health in the first place. In the Indian context, how many of the suicides committed or attempted by queer people can be linked to mental health problems arising from socio-legal stigma around genders and sexualities that do not fit the so called norms? But then how far have these issues been studied in India?
Mental health concerns of queer people in India little understood, long neglected
Whether it is availability or accessibility of mental health services, the tragic fact is that this is a long neglected public health and human rights concern in India. As Mohit Ranadip pointed out in his presentation, while the social stigma against mental ill health itself is a barrier, queer persons with mental health concerns have to deal with a ‘double stigma’. This aspect has been even more neglected because of deep-rooted biases against any kind of variations or differences in gender and sexuality. And this holds true for mental health professionals as much as it does for larger society.
According to the symposium announcement on Facebook, though queer friendly mental health professionals have been strong allies of the Indian queer movements for a long time now, such support has been largely sporadic and from individual practitioners. After the Supreme Court of India reinstated Section 377, Indian Penal Code in December 2013, the Indian Psychiatric Society (IPS) issued a statement (in early 2014) clarifying that they did not consider homosexuality to be a mental disorder. This statement was repeated ahead of the recent, potentially conclusive, hearings on Section 377 in the Supreme Court.
The Mental Healthcare Act, 2017 also emphasizes non-discrimination on grounds of sexual orientation (and gender identity). Internationally, the World Psychiatric Association and the World Health Organisation (WHO) have taken positive steps in clarifying that non-normative genders and sexualities should not be considered a mental disorder. For instance, gender identity disorder as a concept is on its way out and has been replaced by gender dysphoria and gender incongruence in international classifications of mental health problems. Such a change places transgender people on a somewhat better footing in terms of reducing stigma against them and improving access to healthcare.
Despite these positive developments, the ground reality in India has hardly changed beyond a point. Many healthcare service providers still tout ‘cures’ for queer people and continue to do brisk business (including advertising their services overtly and covertly). Anecdotal evidence suggests that even where there is a basic understanding about gender and sexuality, the quality of mental health services in terms of attitudes and skills of the service providers still calls for improvement. Not to forget that distance and costs also continue to act as barriers to services access for many queer people.
Then again, incidents like the recent one at Kamala Girls’ High School in Kolkata (where the principal forced a number of students to ‘confess’ they were ‘lesbians’) and the West Bengal Education Minister’s homophobic remarks in connection with the incident reflect the inherent institutional prejudices among the very stakeholders who should know better.
According to Pawan Dhall, Founding Trustee, Varta Trust, “The experience of developing the online locator on queer friendly services also pointed at the need to better inform and sensitize both healthcare and legal aid service providers to the mental health challenges faced by queer people.” For instance, a therapist not trained to confront their own biases would not be able to help a queer client adequately.
“Such a situation calls for greater dialogue between stakeholders from different spheres. The imminent Supreme Court verdict on Section 377 makes it even more urgent. Whatever be the verdict, it will impact queer people’s lives. There may be adverse social reactions even if the law is read down, further impacting the mental health of queer people,” said Pawan Dhall while talking about the motivations behind the symposium in his welcome speech.
Highlights from the symposium
The event consisted of panel discussions involving mental health professionals, academics, lawyers and queer activists, and experience sharing by queer community members. The idea was to hear from the panellists their work and thoughts on access to mental health services for queer people. Equally, it was also about hearing from queer community members about their needs and experiences.
After the welcome remarks by Pawan Dhall, Shampa Sengupta of Sruti Disability Rights Centre chaired the first panel titled Counselling: Specific Needs of the Individual and Family. She opened the discussion saying, “Why does a webzine like Varta need to exist? There are so many magazines online and offline in so many languages. Are they talking about us? Are they addressing our issues? Are they addressing them in ‘our’ language and approach? It’s a fact that queer people are always conscious of this exclusion, that they are always marginalized that creates the void which a magazine like Varta fills. And it’s these gaps that also make this symposium significant.”
The first speaker, Dr. Madhurima Ghosh, Consultant Psychiatrist, National Neurosciences Centre, Kolkata said she preferred the expression ‘LGBT’ to ‘queer’ as she did not consider the community to be peculiar in any way. She said, “Among the most common ways in which queer people encounter a mental health professional is when their family members bring them in because of conflict around their sexual orientation or gender identity. Addressing the anxieties of family members and breaking myths around variations in gender and sexuality is therefore a big part of my work as a mental health professional.”
Emphasizing more on her experience with transgender clients, Dr. Madhurima Ghosh said among the common mental health problems they seemed to have were self-harm, anxiety around body image, eating disorders and addictive disorders. Many of these were linked to ‘minority stress’, which was an outcome of social stigma and discrimination. She briefly outlined how the thinking around homosexuality and transgender identities had changed over time in the field of mental health.
In the Indian context, Dr. Ajit Bhide, President of the IPS had recently issued their position statement which considered homosexuality a “normal variant of human sexuality”. The IPS had also set up an LGBT Task Force in 2017 in order to address the biases that still prevailed among its own community of mental health professionals, she added.
Shilpi Banerjee, a clinical psychologist based in Gurgaon, made a presentation titled Caring for the Rainbow which was much appreciated by the audience. Right at the start, the speaker explained that they were speaking from the “perspective of a bigender person often mistaken to be a female person and who also had mental health concerns like occasional dysphoria”. In fact, their journey as a mental health professional and the approaches they adopted in addressing the concerns of their clients were rooted in their own experiences around their gender identity and in dealing with personal mental health challenges.
The speaker went on to discuss common concerns of queer individuals like articulation of one’s identity, self-worth, family non-acceptance, challenges in relationships, and workplace issues. They explained how approaches like unconditional positive regard and building knowledge of the interplay of identity and mental health could help mitigate the mental health concerns queer people had. Emphasis on self learning, sharing of learning, safety and comfort, and a change in language were other approaches that mental health professionals could adopt in their work.
Shilpi Banerjee also talked about some of the current initiatives they were part of towards generating awareness around gender and sexuality, creating support networks, and guiding queer people on coping with minority stress and when and how to reach out for support. They said they were engaged in building safe spaces (offline and online) for queer people. These included Undefeated Mind, a Facebook based experience sharing group, and crisis response-based WhatsApp groups.
They were also involved in facilitating networking forums for health and legal aid service providers who often dealt with the problems faced by queer people. One of these was Aparajit Mann that attempted bridge-building among mental health professionals, lawyers and NGOs for a coordinated response to challenges like bullying faced by queer people.
Mohit Ranadip, psychiatric counsellor and social worker associated with Mon Foundation in Kolkata, discussed how mental health problems and queer identities both were stigmatized in our society. This meant that queer people with mental health problems had to deal with a ‘double stigma’. He said that Mon Foundation’s research had revealed a huge gap between the mental health concerns of young people and availability of relevant resources, especially beyond big cities. “Queer adolescents in rural areas have no means to negotiate family acceptance. If they need gender transition surgery, monetary barriers are another major factor. Above all, few among them realize that they can go to a mental health professional if they have a concern related to their gender or sexuality,” he elaborated.
The first panel was followed by a question and answer session that threw up interesting concerns and information on an adolescent lifestyle education initiative by the West Bengal government that unfortunately seemed to have rather distorted ideas on mental health. Pointing out that the government needs to focus on the WHO guidelines for lifestyle education, Mohit Ranadip argued, “There’s a dire need to promote empathy and stress coping strategies in lifestyle education, but none of these have been paid attention to in the government programme. Instead the entire focus is on talking about HIV issues.”
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The second panel Laws, Policies and Beyond was chaired by Pawan Dhall after the lunch break. It looked at the scope of key legislations and court verdicts in protecting and promoting the mental health of queer people. Kaushik Gupta, an advocate associated with the Calcutta High Court and a sexual rights activist, spoke about the Supreme Court’s NALSA verdict on transgender identities and rights. Forward looking as it was, he said that the judgment was extremely belated given the numerous progressive provisions in the Constitution of India.
“The NALSA verdict includes nine directives that talk about various transgender health and well-being concerns, including the need to address the social causes behind shame, dysphoria and fear that transgender persons often experience. But the implementation of these directives has been a huge disappointment. It’s issues like these that have made queer people lose faith in the system. There are both small and larger structural issues in law that have caused much distrust and impacted the mental health of queer people,” he argued. For instance, there is no law that addresses same-sex sexual assault against people assigned gender male at birth.
“These glaring absences in law discourage queer people from stepping forward and taking legal recourse when faced with problems,” Kaushik Gupta commented. Though some forms of social exclusion were beginning to be addressed by the legal system, say, as in the case of people with disabilities, queer individuals were yet to see similar inclusion. Constitutional means must be used to make sure the government took queer mental health concerns seriously, he added.
Disability rights activist Shampa Sengupta talked about the Mental Healthcare Act, 2017 and the history behind the making of this legislation. She said, “It was sort of a forced move, resulting from the signing of the UN Convention on the Rights of Persons with Disabilities by India.” The Act itself had progressive elements, but the reality on the ground was shocking. Apart from talking about the paltry number of registered psychiatrists in India mentioned at the start of this report, she said that the teaching of mental health treatment skills was highly gendered in the country.
For instance, in Kolkata, clinical psychology as a subject was offered only in girls’ colleges. Presumably because our education system deemed that men deserved the medical degree that was associated with psychiatry, while the primarily care giving and counselling role of clinical psychology was best left to women!
On the fact that the Mental Healthcare Act was one of the rare legislations that talked about non-discrimination on grounds of sexual orientation, Shampa Sengupta said, “This aspect of the Act is indeed progressive, but there are inherent contradictions in it as well. Why does the Act say that the mental health services that a person avails must also be acceptable to their family?”
Indeed, what implications would this have for queer persons trying to avail services that were gender and sexuality affirmative but not agreeable to their family members? The speaker concluded that it might be possible to tackle contradictions like these through the rules and regulations for the Mental Healthcare Act, which were yet to be framed at the state level. Several social activists and NGOs in Kolkata had attempted the inclusion of transgender health concerns in a similar exercise at the national level in 2017.
The third speaker in the second panel was Kolkata-based HIV activist Sudha Jha, who was associated with NGO SAATHII. Her focus was the HIV and AIDS (Prevention and Control) Act, 2017. She said that this legislation had come into being after a long struggle of more than a decade. However, despite sustained advocacy by civil society groups and networks of people living with HIV, the government had excluded many positive aspects of the Act over time.
With regard to the implications of the Act’s provisions for queer people, in particular men who have sex with men (MSM) and transgender women, Sudha Jha elaborated that key definitions in the Act like those of ‘partner’ and ‘domestic relationship’ were all hetero-normative in nature. While the definition of a ‘protected person’ was broad enough to include queer persons, in issues like disclosure of HIV status to one’s partner or duty to prevent transmission of HIV, the specific vulnerabilities of queer persons arising from socio-legal stigma around gender and sexuality were not addressed.
The provisions in the Act that exempted sexual health education from the liability of criminal abetment were not in sync with laws like Section 377 or the obscenity laws. For instance, if a peer educator were to distribute condoms to a gay man in a public park, neither individual could be subjected to any legal action. But beyond that, the gay man would continue to be a criminal if he were to have sex with another man (with or without the condoms received). Neither were there any guidelines available on how visually graphic the content of sexual health communication material could be.
The second panel was followed by a number of interesting discussions. Shilpi Banerjee wanted to know if a gender dysphoria certificate was a pre-requisite for a transgender individual interested in carrying out a legal gender identity change. Kaushik Gupta explained that any insistence by a government body for such a certificate would be in contravention of the Supreme Court’s NALSA judgment that allowed for gender self-identification. But as shared by other participants, on-the-ground reality in some states like Delhi seemed to differ.
Varta volunteer Sayan Bhattacharya pointed out that self-identification of gender was important but when it came to accessing State benefits, a certification could very well help in speeding up things, say, as in the case of caste based reservations.
While answering a query on marriage laws, Kaushik Gupta explained that as of now an official marriage in India was not an option for transgender persons (unless they were post-operative transsexual). While the Supreme Court’s NALSA verdict allowed anyone to self identify in their desired gender, the existence of Section 377 meant that any sexual relations, say, between a transgender woman (who had not undergone gender transition surgery) and her male partner could be penalized even if ‘technically’ they could get married as a woman and a man.
In relation to another query, Kaushik Gupta explained that Article 141 of the Constitution stated that all directives of the Supreme Court in any matter were binding on all parties, including the private sector, unless the Parliament passed a specific law to address the matter. This was important information for anyone interested in using the legal route to enforce the NALSA verdict’s directives.
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Rituparna Borah, queer feminist activist associated with Nazariya, Delhi said, “In my experience, education is a site of enormous violence on queer people. There are infrastructural issues that range from lack of adequate and gender neutral or inclusive toilets to absence of gender neutral uniforms. Then there are environmental issues like bullying, gay shaming, sexual violence and the lack of interest among the authorities to address these concerns. Finally, the curricula are overwhelmingly hetero-normative, with no representation of queer identities or desires, and focussed only on the gender binary. As a result, queer people get ‘pushed out’ of the educational system.”
Talking about Nazariya’s work, she said that the organization sensitized both teachers and all students on gender and sexuality diversity (irrespective of whether the students were queer or not). Nazariya also advocated for changes in the curricula to make them more inclusive of queer issues. She added, “We have found that using gender as an entry point to talk about sexuality issues works very well with students. And we find it more effective to talk about gender and sexuality rights rather than focus on LGBT rights at the outset.”
Sharing data on school dropouts from Project Pehchan, a national sexual health programme for MSM and transgender women that SAATHII was involved in from 2010-15, he said that out of 13,257 Kothis and Hijras in Jharkhand, Manipur, Odisha and West Bengal who were registered with the project, 24 percent had dropped out of school by the fifth standard. But the overall dropout rate till the fifth standard quoted in the National Educational Policy was 17 percent.
Adding to this telling statistic, he said: “Bullying adversely affects the mental health and well-being of learners and makes educational settings unsafe and non-inclusive. Once NALSA begins to be implemented on the ground level, and hopefully once Section 377 is read down, the next step would be to undertake major advocacy with the education system.”
Dr. Chilka also spoke about how she had helped queer students over the years in colleges where she had taught. She recollected the story of how a lesbian student who was excellent in studies found acceptance among other teachers only because she had scored high marks! This she said was not quite acceptance.
Talking about the absence of gender and sexuality discourses in the Bachelor of Education courses, she said that surprisingly the norms around sex and sexuality among students in girls’ colleges were becoming increasingly regressive. Transgender activist and Varta volunteer Sudeb Sadhu quipped that regressive values around sexuality seemed to take roots right from Sahaj Path, a Bengali language learning book written by Rabindranath Tagore and popular in schools. Kaushik Gupta stressed the need for talking to students also about non-monogamy as part of gender and sexuality education.
In the discussion that followed the last panel, Rituparna Borah and Brindaalakshmi K., Campaign Manager, ‘Reach OUT’ brought up the issue of disassociating a student’s sexual orientation and gender identity from their performance in studies. They emphasized that accepting a student’s queerness should not be subject to how good or bad they were in studies. Rituparna Borah added Nazariya’s experience: “If teachers say a student’s school performance is bad because of their gender or sexuality, we say then accept their gender or sexuality as it is, if you want a better performance!”
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The symposium ended with a vote of thanks given by Pawan Dhall to all the panellists, audience members, Varta volunteers and staff, and the collaborating agencies. Articles on mental health published in Varta and other literature were distributed. The birthday cake cutting ceremony followed, and Pawan Dhall reminded the participants that Varta Trust would be following up on the actionable points discussed in the symposium (see inset above) in the coming months.
About the main photo: Scenes from the symposium ‘Queering Mental Health’ at Seva Kendra Calcutta Training Centre. Clockwise from top left: Varta literature on display at the symposium; panellists Sudha Jha and Kaushik Gupta; audience interaction during the symposium; panellists Dr. Madhurima Ghosh, Shilpi Banerjee, Shampa Sengupta and Mohit Ranadip; panellists Dr. Chilka, Dr. L. Ramakrishnan, Rituparna Borah and Sayan Bhattacharya; Varta birthday cake. Photo credits: Jia Mata (first two and the last photograph) and Kaushik Gupta (remaining photographs).