Attitude of Doctors Towards Homosexuality at a Medical College, West Bengal, India: A Cross-sectional Study

1. Associate Professor, Department of Psychiatry, Raiganj Government Medical College and Hospital, Raiganj, Uttar Dinajpur, West Bengal, India. 2. Associate Professor, Department of Community Medicine, Calcutta National Medical College and Hospital, Kolkata, West Bangal, India. 3. Assistant Professor, Department of Psychiatry, Institute of Psychiatry- Centre of Excellence, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India. 4. Clinical Psychologist, Department of Psychiatry, Raiganj Government Medical College and Hospital, Raiganj, Uttar Dinajpur, West Bengal, India.

Abstract

Introduction: Attitude towards homosexuality varies differently in different parts of the world. But, almost everywhere social stigma and marginalisation make them vulnerable to poor health and social outcomes. So, physicians should be made aware and sensitive about this issue in order to provide optimal care without any prejudices and discrimination.

Aim: To assess the attitude of the doctors towards the homosexuality at a Medical College, West Bengal, India.

Materials and Methods: A cross-sectional study was conducted for three months from August 2021 and October 2021 at Raiganj Government Medical College and Hospital, West Bengal, India. A predesigned, pretested, structured questionnaire was distributed to each of the faculty members of this medical college. The questionnaire was kept anonymous for name, religion, department or academic qualification and began with asking questions on age and sex. It consisted of 18 statements, nine substatements of relevant attitude along with additional specific comments on the subject. The faculty members were requested to put the filled up questionnaires in a drop box placed at a designated area in the Department of Psychiatry. In this way responses were finally obtained from 56 out of total 69 faculty members. All of them were postgraduate degree holders. The attitude scores were compared on the basis of age and sex using Kruskal-Wallis and Mann-Whitney U tests. A p-value was calculated to find the association of attitude score with age and gender groups.

Results: Among the study participants 21 (37.5%) were in ≥50 years age group, 18 (32.1%) in 40-49 years age group and 17 (30.4%) in ≤40 years age group. Males were 41 (73.2%) and females were 15 (26.8%). Forty six (82.2%) participants agreed that homosexuality is “constitutionally determined” (an inherent fundamental right as per Indian constitution). However 34 (60.7%) did not believe it to be a “sexual orientation”. Half of the participants are of the opinion that “homosexuals are easily recognisable”. Forty three (76.8%) respondents are of the opinion that “homosexuals should not be employed in school”. Also 41 (73.2%) believed that “homosexuals are danger to children”. Only 23 (41.1%) generally agreed that they “did not feel embarrassed while talking about homosexuality”. Just above half of the participants agreed that they “really did not understand homosexuality”. The attitude scores did not however vary according to age (p-value=0.25) or sex (p-value=0.09) groups.

Conclusion: Majority of the study participants had inadequate knowledge on the issues of homosexuality with a more or less neutral stance in their attitude.

Gender identity, Homosexual, Medical faculties, Sexual orientation, Sexual minorities

Originating from both Greek and Latin languages, the term “homosexual” means “same sex” (1). It refers to sexual attraction, sexual behaviour or even romantic attraction between individuals of the same sex. According to American Psychological Association, (2015) sexual orientation refers to an enduring pattern of emotional, romantic, and/or sexual attractions to men, women, or both sexes (2). Hence, it is a part of an individual’s sense of identity based on those attractions and behaviours related to it. Research conducted through several decades has revealed that both “nature and nurture” play a vital role in determining the sexual orientation of an individual (3).

But throughout their upbringing individuals are unknowingly taught that homosexuality is unnatural phenomenon that leads to negative stereotypes, prejudices, and discrimination towards persons with homosexual orientation.

In 2009, the Delhi High Court decriminalised homosexuality, but in 2013 the Supreme Court of India upheld section 377 of the Indian Penal Code which criminalised consensual acts of same sex in adults (4),(5). However, in 2014, the Supreme Court granted constitutional recognition to transgenders as the third gender and any discrimination towards them was considered a violation of their constitutional rights (6). Later on in 2018 a historic judgment of the Supreme Court made Section 377 unconstitutional and recognised adult gay sex as an outcome of natural sexual orientation over which people have no control. Since then, homosexuality got legal approval and recognition in India (7).

Attitude towards homosexuality varies differently in different parts of the world. However almost everywhere the sexual minorities, including Lesbians, Gays, Bisexuals, and Transgenders, Queer, Intersex and Asexual (LGBTQIA) community) are universally subjected to verbal and physical violence and hence experience a higher degree of psychological distress like depression, anxiety and attempted suicide compared to the general population (8),(9),(10). Moreover, social stigma and marginalisation make them vulnerable to poor health and social outcomes (11),(12),(13).

The doctor-patient relationship plays a vital role in improving the health of individuals. It has been seen that the ways of interaction of physicians or other health professionals with individuals from the LGBTQIA community can greatly affect their perception and utilisation of health services (14). Many a times individuals from the LGBTQIA community have to face negative behaviour and hostility from health care professionals upon disclosing their sexual orientation for any reason whatsoever and due to this they often hesitate to access health care services even in the time of emergency (15),(16),(17),(18). So, physicians are needed to be made aware and sensitive about this issue in order to provide optimal care without any prejudices and discrimination (19). In this backdrop, the United Nations in 2019 emphasised the need to educate the healthcare providers on LGBT issues (20). Furthermore, medical teachers also play a crucial role in better preparing medical graduates to interact and communicate with these marginalised communities and enabling them to access the services without the fear of discrimination (21). As per authors’ knowledge though there are many studies on attitude towards homosexuality in India among medical students, youth groups and others, very few involved medical faculties. The present study dealt with this subject matter from the perspective of medical teachers cum doctors.

The authors of the present study had a previous experience in conducting a similar study on undergraduate students but not with medical faculties (22). The attitude of medical teachers cum doctors towards homosexuality plays a pivotal role in providing respectful health care services to the sexual minority group. A medical teacher’s positive attitude in this matter is also supposed to have a positive influence on the attitude of their students who will be the future consultants. So, the assessment of knowledge and related attitude of the medical teachers would in turn aid in assessing their orientation and training needs on this very vital issue. As such there is no hypothesis of the study. With this background, the present study was undertaken to assess the attitude of the doctors towards the homosexuality.

Material and Methods

This cross-sectional study was conducted between August 2021 and October 2021 among the faculty members, all of whom had postgraduate degree in their respective subjects (as was observed prior to the beginning of the study from the academic record section of the institution), posted at Raiganj Government Medical College and Hospital, West Bengal, India. The ethical clearance was obtained from the Institutional Ethics Committee (IEC/RGMCH/21).

Inclusion criteria:

• Medical teachers with postgraduate degrees.
• Permanently posted in the said medical college.
• Who gave consent to participate in the study.

Exclusion criteria: General duty medical officers who were not involved in teaching and those faculty members who did not give consent or responded back were excluded from the study.

Study Procedure

All the faculty members available at the time of the study were approached and given the questionnaire and an informed consent form. They were requested to fill this anonymous, predesigned, pretested, structured questionnaire and put them in a drop box placed at a designated area in the Department of Psychiatry. Those who gave consent and also responded back with the duly filled-up questionnaire during the study period were included in the final analysis of the study. In this way out of the total 69 faculties of different departments (present at the beginning of the study), 56 responded back and included in the study with a response rate of 81.2%.

Questionnaire

The questionnaire was in English and used earlier by Kar A et al., among Indian medical students after it was validated and checked for reliability (Chronbach’s alpha of 0.91) (22). Necessary permission was obtained for using this questionnaire in the present study. The questionnaire was kept anonymous for name, religion, department or academic qualification and began with asking questions on age and gender. It consisted of 18 statements, two of which had altogether nine substatements (four substatements in statement one and five in statement 17) for additional specific comments on the subject. There were five responses for each statement: strongly agree, generally agree, unsure, generally disagree, and strongly disagree on a 5-point Likert scale. In order to reduce response bias, the phrasing of statements, in positive or negative sense, was balanced and reverse scoring was assigned for statements that showed unfavourable attitudes. These statements were “I believe that homosexuality is an illness”, “Homosexuality in general is result of disturbed relationship with one or both parents”, “Homosexuals in general are neurotic”, “Homosexuals in general are easily recognisable”, “Homosexuals in general are promiscuous”, “Most male homosexuals have effeminate trait and female homosexuals have masculine trait”, “Most male homosexuals would prefer to be females”, “Most female homosexuals would prefer to be male”, “Homosexuals should not be employed in schools”, “Homosexuals are danger to children”, “Scientific material and reading of homosexuality has not really affected my views on subject”, “In my opinion causes of homosexuality are seduction experiences in childhood, fear of heterosexual activities, insufficient contact with the opposite sex at puberty, unsuccessful heterosexual experiences” and “I do not really understand homosexuality”.

In case of favourable attitudes a score of 5 was assigned to the response “strongly agree” and 0 to the response “strongly disagree” like in statements 1a, 1b, 1c, 7, 8, 14, 15, 16, and 17a. Whereas, in case of unfavourable attitudes a score of 5 was assigned to the response “strongly disagree” and 0 to the response “strongly agree” like in statements like 1d, 2, 3, 4, 5, 6, 9, 10, 11, 12, 13, 17b, 17c, 17d, 17e and 18.

Statistical Analysis

Data were analysed using Statistical Package for Social Sciences (Windows version 20.0; IBM Corp, Armonk NY, United States of America). The attitude scores were compared on the basis of age and sex using Kruskal-Wallis and Mann-Whitney U tests at 5% significance level.

Results

Among the study participants 21 (37.5%) were in ≥50 years age group, 18 (32.1%) in 40-49 years age group and 17 (30.4%) in ≤40 years age group. Majority were male (n=41, 73.2%) and only 15 (26.8%) were female (Table/Fig 1).

Majority (n=46, 82.2%) of the participants agreed that homosexuality is “constitutionally determined”, but did not believe it to be a “sexual orientation” (n=34, 60.7%). Thirty two (57.1%) did not consider it “an illness”. Seventeen (30.4%) participants had the opinion that “homosexuals in general are neurotic”. Half of the participants were of the opinion that “homosexuals are easily recognisable”. Among the participants 21 (37.5%) had the idea that “homosexuals in general are promiscuous”. It was observed that 24 (42.8%) remained unsure whether “most male homosexuals have effeminate trait and female homosexuals have masculine trait”. Only 3 (5.4%) participants agreed to the statement “in general homosexuals are capable of forming stable relationships”. A large proportion of the participants did not feel that “homosexual doctors would treat homosexual patients with better understanding”. Also, 43 (76.8%) are of the opinion that “homosexuals should not be employed in school” and 41 (73.2%) believed that “homosexuals are danger to children”. Altogether 35 (62.5%) participants opined that reading scientific materials about homosexuality had not really affected their views on the subject. It was also found that 26 (46.4%) were unsure whether “the problem of homosexuality could be reduced if the society were to liberalise its attitudes” (Table/Fig 2).

Only 23 (41.1%) generally agreed that they “did not feel embarrassed while talking about homosexuality”. While 17 (30.4%) did not agree to the statement “homosexuality is an innate predisposition”, 16 (28.6%) did agree to it. Majority did not believe that homosexuality was caused by “seduction experiences in childhood” (n=26, 46.4%) or “fear of heterosexual activities” (n=38, 67.9%). However, a good number of participants were also unsure whether homosexuality was an innate predisposition (n=21, 37.5%) or resulted from seductive experiences in the childhood (n=18 32.1%) or unsuccessful heterosexual experiences (n=22, 39.3%). Just above half of the participants agreed that they “really did not understand homosexuality” (Table/Fig 2). The attitude scores did not however vary according to age (p-value=0.25) (Table/Fig 3) and gender (p-value=0.09) groups (Table/Fig 4).

Discussion

Not much is found regarding homosexuality in Indian medical journals. This is one of the few studies where attitude of doctors toward homosexuality in Indian context was explored. The present study revealed an inadequate knowledge among the study participants regarding homosexuality, though majority maintained neutral stance regarding their attitude towards this issue. In the present study, majority (82.2%) of the participants agreed homosexuality to be constitutionally determined but did not believe it to be a normal sexual orientation (60.7%). Also, 48.2% strongly disagree that this is an acquired behaviour. Vijaylaxmi et al., in their study among college students across India recorded that 45.2% of the participants agreed that homosexuality could come as a choice, 49.04% had the opinion that “it happens” (23). Only to 7.2% homosexuality was not an acceptable phenomenon (23). In the present study, 26.8% generally agreed and 3.6% strongly agreed that homosexuality could be caused as a result of disturbed relationship with one or both parent. Another, 33.9% subjects were unsure about it. Also 33.9% generally agreed but 23.2% strongly disagreed that they are promiscuous. Among the respondents, 28.6% generally agreed that male homosexual are effeminate trait and female are masculine trait in the present study. In a study conducted by Kar A et al., 58.8% of the participants believed that male homosexual showed effeminate trait and female homosexual had masculine trait while 28.1% believed that homosexuals were promiscuous (22). In the study by Vijaylaxmi et al., reported that majority of the study participants believed that they could detect the sexual orientation of individuals just by looking at them (23).

The present study did not reveal any significant difference of attitude towards homosexuality with respect to age or sex. A survey conducted by Mathews WC et al., on physicians’ attitudes toward homosexuality reported that male doctors were more homophobic than female doctors (24). In a survey conducted by Smith DM and Mathews WC on physicians’ attitudes toward homosexuality and HIV also found significant differences in prevalence of homophobic attitudes by gender (25). In a study conducted by Matharu K et al., observed that male students and students younger than 25 years were more likely to have negative attitudes towards homosexuals (26). A study by Grabovac I et al., also reported more positive attitude towards homosexuality among the female medical students (19). In a similar study Banwari G et al., observed that female medical students had lesser negative attitude towards homosexuality (27).

Due to lack of availability of research articles regarding this in Indian context, it is very difficult to comment on how much stress is given in medical curriculum regarding homosexuality and their health related issues in India. Sometimes Indian medical textbooks give misleading information about homosexuality that promotes bias among medical professionals (28). It is quite apparent that the subject does not get its due importance in medical textbook or medical curriculum which is reflected in the low level of knowledge regarding this in the present study. It is recommended that the subject of homosexuality and the relevant health issues be included in the medical curriculum and the need for necessary faculty orientation and training programmes be duly emphasised in order to render discrimination free health care services to the community.

Limitation(s)

Sample size was small. Structured questionnaire could not get into the reason behind the observed attitude and its perspective. Qualitative analysis with in-depth interview could have been a better alternative to delve into issues. Nevertheless, the present study has definitely provided some basic insight to the level of awareness and related opinion among the medical faculties regarding homosexuality.

Conclusion

It can be concluded from the present study that the majority of the study participants had inadequate knowledge on the issues of homosexuality with a more or less neutral stance in their attitude. Quite a substantial proportion of the participants expressed an unfavourable attitude towards the employment of homosexuals in school and children not being safe in their presence. However, the overall attitude did not significantly differ between age and sex groups.

DOI and Others

DOI: 10.7860/JCDR/2022/59134.17302

Date of Submission: Jul 17, 2022
Date of Peer Review: Sep 03, 2022
Date of Acceptance: Nov 16, 2022
Date of Publishing: Dec 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 18, 2022
• Manual Googling: Sep 28, 2022
• iThenticate Software: Nov 15, 2022 (8%)

ETYMOLOGY: Author Origin