Social Identity, Health Rights and Medical Ethics: An Analysis of the Attitudes of Caregivers of Public Health sector in the Medical Care of Transgender People in Côte d’Ivoire

doi:10.21203/rs.3.rs-1948741/v1

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Social Identity, Health Rights and Medical Ethics: An Analysis of the Attitudes of Caregivers of Public Health sector in the Medical Care of Transgender People in Côte d’Ivoire

https://doi.org/10.21203/rs.3.rs-1948741/v1

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In Côte d'Ivoire, as in many other parts of the world, Lesbian, Gay, Bisexual and Transgender (LGBT) people in general, and transgender people in particular, face enormous difficulties in accessing care. They are victims of their social identity and are stigmatized and marginalized from the health care system. In most public health structures, their medical care is problematic due to the reluctance of health care providers. We are witnessing less responsible attitudes among some caregivers in public health sector. According to the literature, LGBT people are vulnerable to several diseases, including HIV/AIDS. As such, they require specific health care. This situation experienced by LGBT people constitutes a denial of the right to health and of medical ethics. Indeed, health is a universal right that advocates equal access to health care. As for medical ethics, it requires caregivers to have a humanitarian duty, probity, loyalty and respect for human life. Thus, regardless of the patient's status, social identity, the caregiver's vocation and duty is to administrate the necessary care, while respecting professional secrecy. Between law, ethics and attitudes, this socio-anthropological research conducted among caregivers and transgender people in particular, proposes to understand this paradox, this contradiction that results in Côte d’Ivoire. In other words, it analyzes the attitudes of caregivers in the medical care of transgender people in a context of universality of health, right to health and ethical principles governing the medical profession in Côte d’IvoireBouaké.

Sociology

Social identity

Right to health

Medical ethics

Transgender people

Caregivers

Attitudes

While Western societies are evolving and working more and more towards the integration of LGBT people, in Africa they live in secrecy, silence and clandestinity (Vézina, 2009). Yet, these categories of people, if not their practices, have always been known and practiced in Africa before colonization (Gueboguo, 2006). According to Sika and Kacou (n.d), homosexuality is not a new reality in Africa. For them, far from being a new reality and wrongly considered as a product of Western culture, homosexuality is a well-known practice in African societies. They cite Tauxier (1912), who identified this type of sexual practice among the Mossi of West Africa in present-day Burkina Faso, as proof. They took place in the royal court and were aimed at obtaining from the aristocracy a conformity to the social norm which prohibited heterosexual practices on Fridays.

Today, even if these practices are not yet accepted, it must be recognized that they are strongly anchored in Africa. We are even witnessing the birth of associations of LGBT people, particularly in Côte d'Ivoire. We have, among others, the Young Homosexuals Association of Côte d’Ivoire (YHACI) of 1500 people divided in about twenty houses. In a publication made on September 16, 2007, the secretary of this association wrote this: "we are an association of young homosexuals (AJHCI) residing in Ivory Coast wishing to be known in the world and also to be impregnated with the realities of our friends. Indeed, this association was born on 01/03/2001 in an unofficial way because in Africa it is difficult to admit the homosexuality of others, which is why we are marginalized and rejected. (...) We live in promiscuity..."(http://www.archiveshomo.info/escroquerie/ajhci.htm ).

This denial, this exclusion of LGBT people, which the Secretary's words denote, is still relevant today, particularly in the medical field, despite their right to health. The right to health is the right to the highest attainable standard of health, which implies both entitlements to benefits and freedoms (understood as a system of health protection that gives everyone access to benefits without discrimination on any grounds and the right to control one's own body, including sexual and reproductive freedom, and to be free from medical treatment that is not freely accepted, experimentation, and torture (Anonymous, n.d). However, the finding is that LGBT people are social minorities who are discriminated against, prejudiced, and victims of social inequalities in access to care (Scime, 2019; PREOS, 2012).

Several factors account for the violation of the health rights of LGBT persons. These include socio-cultural and religious pressures and burdens on the one hand, but also the lack of training of health professionals, the majority of whom are not trained in LGBT issues (Vézina, 2009 ; PREOS, 2012). But, could the attitudes of health caregivers towards the care of transgender people be linked to this lack of training ? In other words, how, in a context of universality of health, the right to health, and ethical principles governing the medical profession, can we explain the attitudes of caregivers to the medical care of transgender people ?

This research aims to analyze the attitudes of caregivers in the medical care of transgender people in a context of universality of health, the right to health, and ethical principles governing the medical profession, and to understand the experience of this social minority in accessing care in Côte d’Ivoire.

This research was conducted in Abidjan and Bouaké. Based on a qualitative approach, it involved public health care providers, transgender people and humanitarian actors working in favor of social minorities. It is based on qualitative data that was collected using technics such as life stories, semi-structured interviews and document reviews with these different categories of actors. The present text is therefore based on a corpus of varied data that were processed using the qualitative data processing software Nvivo 12.

In addition, the collection of data and the writing of the article were done in strict compliance with the ethical considerations in force in the field of social science research. The dignity and privacy of the actors and the principle of confidentiality were therefore respected. Respondents were informed about the nature of the research, its possible benefits and risks, and their rights to participate or not. Thus, their participation was free and informed. The identities used in the text are fictitious first names that we have assigned to the respondents in order to sacrifice the principle of pseudonymisation.

THEORETICAL FRAMEWORK

The theoretical framework chosen for the data analysis is based on Tajfel and Turner's social identity theory. According to Autin (n.d), citing Tajfel and Turner (1979, 1986), "social identity theory is part of the study of intergroup conflict. It posits that categorization into two distinct groups alone results in discrimination against the exogroup in order to differentiate its group. The stake of the differentiation is a positive collective identity, this one resulting from an intergroup comparison favorable to the endogroup ". According to him, "the social groups thus provide to their members a social identification called "social identity". As for his approach of the social identity, he defines this one as "the part of the self-concept of an individual which results from the conscience that this individual belongs to a social group as well as the value and the emotional significance that he attaches to this membership". To conclude, he postulates that "the interest of the theory of social identity lies in the integration of various processes in a coherent and testable theoretical framework. It combines social categorization, self-evaluation through social identity and intergroup comparison to provide an explanation for different forms of social behavior, social conflict and social change.

The operationalization of our research in the light of this theory makes it possible to identify the groups present and in conflict. On the one hand, we have the group of caregivers, which is considered here as the endogroup. On the other hand, we have the group of transgender people whose identity is different from the social norm and who would constitute the exogroup because of their transidentity. These two groups with different social identities, but assumed by each of their members, are thus in a conflict relationship where the exogroup is a victim of discrimination, of stigmatization in the access to care in public health structures. Based on this social categorization of the actors concerned, this article analyzes and allows us to understand the attitudes of caregivers towards transgender people in public health structures. More importantly, it examines the ways in which caregivers express stigmatization of transgender people on the one hand, and the logics that underlie caregivers' attitudes on the other.

Analysis of the data collected highlights a set of attitudes that stigmatize transgender people.

Stigmatizing attitudes

In public health facilities, all of the transgender people surveyed said that they were victims of stigmatization and discrimination by health care providers and others. According to them, the main problem they face in public health centers is stigmatization. This statement by the transgender people interviewed was corroborated by resource persons working in favour of sexual minorities in Bouaké. For them, in addition to stigmatization in the family, social and professional environment, LGBT people in general are also victims of stigmatization in access to care in the public sector in Côte d'Ivoire. These people are victims of discrimination in public health structures," said a public health caregiver. The analysis of the data collected from the actors surveyed made it possible to highlight the different attitudes of the caregivers towards them.

Denial of transgender care

One of the variants of stigmatization in the hospital environment collected from the actors surveyed is the refusal of care to transgender people. Indeed, it appears that some caregivers are hostile and refuse to receive them in consultation and to give care to them because of their social identity which clashes with the social norm. Like the others, one respondent told us

[We are stigmatized in hospitals. Some people just refuse to treat you because you're an effeminate person. It's shocking, it's shocking. No, but it's shocking because sexual orientation has nothing to do with the life you live. A sexual orientation is a sexual orientation, period. You can't say that you don't talk to someone or you don't like someone just because he is gay or just because he is heterosexual. It's silly but there is something in each of us called free will. Everyone is free to like what they want, everyone is free to do what they want. So, they are free to want us, they are free to refuse us. It's their choice] Pauline, male transgender.

On the other hand, a caregiver tell us this:

[Often, even when they receive them, the care is not of quality. They try to get rid of them and generally the prescription is not well done, it is terse. Normally, they should receive them well, give them the necessary care and refer them when necessary to competent or specialized structures] Philippe, public sector caregiver.

The statement above reflects the social discomfort that transgender people experience in accessing care in public health facilities. Their rights to health care are violated because their social identity is not tolerated by some health caregivers. In addition to the refusal of care, the transgender people interviewed stated that they were offended by the derogatory and hostile looks they received.

Caregiver’s views on transgender people

In public health facilities, it is noted that transgender people are a kind of attraction not only for caregivers but also for users. One of the reasons given is their effeminate appearance. Their presence would attract derogatory looks that offend their sensibilities.

[Actually, i just go to hospitals that are more open to my sexual orientation, that are more open to the transgender issue than other hospitals because i feel more comfortable here. Because i tell myself that maybe on the other side, they are not going to open their mouths to tell me to my face what they think of me, what they think of me. But the looks or even the way people do things can offend my sensibilities] Félicienne, transgender man.

[But we, when we get there, our entrance only even… We will let the employees. Even the patients who are in the hospitals, when we arrive there, when they turn, looks they give you there, you are cured. Where you are there, you heal from the disease you had, it leaves in your body. The look are like injection. You turn around] Carine, male transgender.

This hyperbole that we can notice in the second paragraph of the statement above, testifies to the hostility of the looks projected on this group of people in the public health centers. Consequently, these public health structures are perceived by these transgender people as spaces marked by violence and dislike in which they do not benefit from the solidarity and care of health care providers, but rather from an unacknowledged but certain contempt. Moreover, in addition to the refusal of care and hostile looks, some transgender people declare that they have been victims of direct humiliation by caregivers.

Humiliation experienced by transgender people

The analysis of interactions between caregivers and transgender people shows that this identity minority are often victim of humiliation or frustration in the public sector. In this regard, we have collected the account of a male transgender respondent in which he tells us about the humiliation he would have experienced in a public health center because of a female caregiver. In his words:

[As he said, we are stigmatized everywhere. And if i had to tell a story about what i've already experienced, i'm going to dwell on what i experienced. Well, i had just finished doing the sidewalk and i was going home. In the meantime, i had an appointment to take my medication. When i arrived, usually when i go, it's the doctor i find or the nurse. And this day when i arrived, it was a lady that i found. Generally, we with the men, it is a little difficult when we are dressed as a woman. It is a little difficult for them to know if it is a man or a woman. With women, it's a little more easier than with men. So, i was there, i arrived, she asked me for my code. I gave her everything. I don't know if she looked in my files, i don't know if she saw sex wrong or right. But in front of people, while there were people, she asked me if i were a man or a woman. Really there, i felt very humiliated. And since i left there, I was forced to change hospitals. I never arrived there again. Well, me after my bad experience, seriously I don't go to the public centers anymore] Eveline, male transgender.

In analyzing this account, we note that the question publicly addressed by the caregiver to this respondent about his gender, despite his file and in view of his appearance, thus reflects a clear desire on the part of this caregiver to humiliate him. In doing so, she exposed him to the gaze of other users of different social identity. Furthermore, this analysis by the respondent is understandable since the data show that transgender men are generally dressed as women. For this respondent, he would be dressed that day in a dress.

Denial of care to transgender people, hostile looks and public humiliation are indicators of stigmatization that emerge from the data analysis. This social minority would therefore be a victim of the attitudes of some public sector caregivers, due to their disavowed social identity. However, how can these attitudes be explained ? Otherwise, what are the logics, the rationalities that underlie these attitudes observed among caregivers in public health structures ?

Logics related to the attitudes of caregivers

It emerges from the analyses that several rationalities underlie the attitudes described above attributed to caregivers in public health facilities. These include lack of professional awareness, lack of gender training and lack of understanding of LGBT issues in general and transgender issues in particular, and the conflict between cultural and religious principles and transidentity.

Lack of professional awareness

According to transgender respondents, caregivers' attitudes towards them are related to a lack of professional conscience. This perception is based on the fact that they believe that caregivers should respect the privacy of patient, their private lives and avoid exposing them publicly despite the implications of doing so. In addition, we note that these caregivers are not fully aware of the risks associated with their attitudes. Indeed, because of the forms of stigmatization they face, some transgender people may stop going to the health center and stop their treatment since they are often people living with HIV. Even worse, family members of caregivers may be LGBT but refuse to come out because of fear of stigmatization. This analysis could be illustrated by the following statement, among many others:

[I'm going to say already that it's unconsciousness. It's unconsciousness because being HIV positive, everybody is exposed to this disease. Everyone is exposed to this disease. If we write on a board or project the private life of each one of us, no one will have the right to open their mouth to say anything about the other. So, this is already an act of unconsciousness. Because even their children who are at home, they don't even know, they don't have the ability to see what is going on inside their blood. So, they don't know what they really have. So, it's unaware and really i hope that one day the mindset will change] Pauline, male transgender.

These social implications related to transgender stigmatization were hammered home by the caregivers and local NGO actors interviewed. For these resource persons, the stigmatization of LGBT people is a real public health problem. Indeed, as people who are highly exposed to diseases such as STIs and HIV/AIDS, silencing them could lead to the spread of these diseases in society. Some of them having sexual relations with multiple partners who don’t know their serological status.

Lack of training on gender and LGBT issues

For both transgender respondents and the humanitarian actors surveyed, public sector caregivers lack knowledge and information about LGBT issues. In general, most of them are not trained in gender issues and especially those related to LGBT. Thus, the real needs of these social minorities in terms of care are not mastered by the public caregivers. In other words, they are not specialists in the care of these specific groups of people. Thus, for them, the attitudes of public caregivers are determined by the lack of training on LGBT health issues.

[So, i would say it's ignorance because sometimes you go to the health centers like the one who was there before wished. He didn't have any concern yet he wasn't homosexual but he accepted. I tell myself that maybe he received a training where they talked to him about gender. But this last one, i don't think she received training on that. I tell myself that it is someone who perhaps does not know. She has no information] Christine, male transgender.

[There are no technical platforms in public hospitals for trans people because a trans person is really a person who has a feminine state, who has the normal sex that is assimilated at birth, that is to say a woman who was already born a woman who has breasts. The state of trans, you are approaching to be a woman that is why you start taking hormones. But are they trained on the prescription of hormones ? Do they already know what hormones are ? Do they know that a man can take hormones to have breasts, to have a fine voice, to break his hips ? do they know that ? They don't know all that. You see a doctor, he will tell you "hey, what's that? I was in medicine for 8 years, they never told me that. So, there is already that first, so they have no knowledge of information, they have nothing. There's nothing in the manual, there's nothing in the training, and on top of that. All of that's part of the stigma] Denise, male transgender.

Furthermore, we note that humanitarian actors, public sector caregivers do not have knowledge of the often codified language of LGBT people, which makes interactions difficult and delicate.

Conflict between culture, caregiver’s religion and transgender people

The attitudes of caregivers in public health facilities are also a function of the cultural norms of reference of caregivers and their religious values or principles. A conflict emerges between these socio-cultural and religious realities of caregivers and the social identity of transgender people. Trained to respect their cultural and religious values, the caregivers are outraged by this social group, which translates into the refusal of care, hostile looks and humiliations that they perpetrate against the members, i.e. the transgender people. Thus, the hostility of religion and the cultural values of origin of the caregivers will shape their view of these people whose identity and values are perceived as unnatural. The following comments, collected respectively from transgender people, humanitarian actors and caregivers, do not say less. In fact, according to the transgender people interviewed:

[We can talk about ignorance. And then, i don't know if i can say religion because someone in their religion, they are told him that it is not good. I don't think that the person will accept whatever they are told. I don't think that they will accept it because already in their religion, they are told that it is not good. So it is in their head. They will not accept whatever they are told] Carole, male transgender.

[If we were not stigmatized, if there were no bad looks, if there were no criticism, if there were no negative opinions, we would feel like a family. Here, we are open to you because we are quiet. You see, before asking us questions, you already respected our sexual orientation. You knew how to approach the conversation with us. But we don't even sit down with someone who is not open on a subject while the person is telling us that even in our religion, we have been told that you are people, we have to slit your throat, we have to kill you. You, you think what ? But a long time ago, we insulted him] Eveline, male transgender.

This view is shared by some of the humanitarians and caregivers interviewed:

[You know, health workers are also attached to cultural and religious values. In general, no religion and society does not accept this practice. So, that's also what makes these health workers behave that way] Raoul, humanitarian.

[There are some health workers who put themselves in the shoes of the pastor instead of the scientist. Instead of receiving the patient, they will reject him or admonish him. For them, this is a violation of God's will. So it's religion. The second cause, in my opinion, is tradition too. It's practices that are forbidden in society. So people don't accept that] Philip, public sector caregiver.

As we can understand, caregivers' attitudes towards transgender people are underlied by a tangled web of factors related to professional conscience, lack of training on gender and LGBT issues, culture and religion that are unfavorable to the social identity of this minority.

The scientific debate that we are conducting here around the results of this research, is made in reference to two universal principles in the first place. These are the principle of the right to health and the principle of medical ethics. Secondly, we take a critical look at the social implications of the stigmatization of LGBT people in public hospitals.

Health rights and LGBT stigmatization: what contradictions ?

When we look at all the health rights benchmarks, what we essentially retain is that health is an inalienable human right. According to the declaration of the Alma-Ata conference held in 1978, in its point 1: "health, which is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, is a fundamental human right, and that the attainment of the highest possible level of health is an extremely important social objective which concerns the whole world and implies the participation of many socio-economic sectors other than the health sector" (WHO, n.d). This principle was the first to be included in the preamble of the WHO Constitution, which was drafted in 1948 (David, n.d). In addition, according to SDG 3 on Access to Health, individuals must be empowered to lead a healthy life and support the well-being of all people at all ages. All of these universal principles, therefore, advocate for equal access to health care for all people. This means that regardless of a person's difference, status, and especially social identiy, which is a choice, they are entitled to receive care in public and private health facilities. This is a fundamental right that should be respected by all and especially by the caregivers who are involved in this research. But, if we refer to the results of this research, we note that there are strong social inequalities in access to care and that transgender people are victims in public health structures. Because of their social identity, which is considered unnatural and a violation of God's will, transgender people are stigmatized insofar as they are often denied care in public health facilities. They are the target of hostile looks and humiliation. Previous research on LGBT issues corroborates our results. Indeed, the literature we have reviewed shows that LGBT people are generally confronted with harassment, intimidation, threats, aggression, hatred, discrimination and social exclusion because of their identity in society (Clermont M., Sioui-Durand G. 1997; Dumas, 2013; Scruton, 2014; Kamgain, 2015; Donnat et al.). Also, it emerges in the majority of studies, that LGBT people resort to clinics, i.e. the private sector and specialized structures. This research also points to the issue of training of caregivers on the themes, Standards of Care (SOC) (WPATH, 2012) or clinical guidelines for the care of LGBT people and cultural and religious constraints. In addition, some research has looked at the relationship of caregivers to LGBTQ people in order to understand the explanatory factors of care avoidance among these minorities. Similar to our research findings, the main finding is that transgender people who have experienced transphobic prejudice or who have been refused an appointment on the basis of their transgender status by health care providers are more likely to forego care (Guide-Chrysalide, n.d).

We can say that there are gaps between the norm dictated by the referentials in terms of equality and rights to health and the reality on the field, in terms of inequalities, stigmatization of transgender people in public health structures due to the intolerance of their transidentity by society and particularly by some caregivers.

Medical ethics and the stigmatization of LGBT people: What contradictions ?

The analysis that we propose here is based on texts, oaths that govern the profession of care (doctor and nurse) in a general way and that we should recall here. The first is that of Hippocrates (http://www.cmq.org/publications-pdf/p-1-1999-12-01-fr-serment-hippocrate.pdf) and it concerns doctor while the second, is by Nightingale (https://medicactu.com/2107-serment-nightingale) and concerns nurse.

In a scientific publication on the analysis of the relationship of caregivers to patients' medications from an ethical perspective, Ouattara et al., (2017) note that these texts or oaths represent "international norms and standards of good practice" that dictate the ethical values embodied or to be embodied by caregivers. These include the values of respect for hierarchy and patients, moral probity, helpfulness, and promotion of health and human life at all levels, for every human being in a committed manner. However, the results of the present research highlight a denial, the non-respect of values or principles of medical ethics among public sector caregivers in the care of transgender people. Indeed, the refusal of care, the hostile looks and the humiliations of which this minority is victim because of certain caregivers, testify to the violation, the transgression of the ethical norms by these latter. These caregivers, far from directing the regime of the patients, the transgender people in this case, to their advantage, according to their strengths and their judgment, and by abstaining from any evil and any injustice, would have been guilty of the opposite, we can deduce.

As with health rights, there are also gaps between the normative ethical principles dictated by oaths about the quality of caregivers and their actual attitudes decried in the field, particularly with regard to the medical care of transgender people. However, what might be the social implications of stigmatizing this social group?

Stigmatization of LGBT persons: what are the social implications ?

The stigmatization of LGBT persons carries major risks for public health. The literature on LGBT people unanimously notes their vulnerability to diseases such as HIV/AIDS. However, LGBT people include bisexuals. Hostility and discrimination against them can be a factor in the spread of the disease. Indeed, as demonstrated by a study conducted in Côte d'Ivoire by Sika and Kacou (n.d), men who have sex with men (MSM) are at high risk of HIV/AIDS. They show that out of 468 male sex workers (MSM) interviewed, more than half (57%) reported having ever had sex with at least one woman. On average, they had 2 female sex partners in the 12 months prior to their survey. In addition, 2 out of 4 (52%) sex workers had sex with at least 5 partners during the reference period indicated. These results indicate that bisexuality increases the risk of spreading HIV/AIDS. In turn, the failure to take these social groups into account in HIV/AIDS policies could negatively impact and ruin the efforts of stakeholders. The results of our research confirm these risks insofar as some of the transgender respondents state that others among them are sex workers, MSM and people living with HIV (PLWH). To these risks, we must add psychological disorders, malaise (Delebarre and Genon, 2013) and the risk of renouncing care (Guide-Chrysalide, op.cit) with all that this implies about stigmatized transgender people.

Thus, the stigmatization of transgender people in public health facilities carries significant risks for both society and themselves. These risks can be prevented by respecting the health rights of this social group (Vézina, 2009).

This research has allowed us to assess the relationship between caregivers and social minorities in access to care in public health facilities. We note that this relationship is conflictual and to the disadvantage of transgender people in particular, but of LGBT people in general. Indeed, although equality of men in access to health care is a universal principle advocated by international organizations (WHO, UNICEF, and others) and by States, access to health care remains problematic in the public sector for social minorities, including transgender people. Socio-cultural and religious constraints, hostile attitudes of health care providers and lack of training of public sector health caregivers in issues related to the health needs of these social groups are among the major obstacles to access to health care in private health care facilities for these social groups.

Social identity theory allows us to understand that transgender people are not well tolerated because their social identity is considered unnatural and clashes with the social norms and values to which caregivers are attached.

However, the issue of this research is at the level of public health. Indeed, without promoting this social minority or identity, it draws attention to the need to take them into account in health policies, to respect their rights to health, to integrate them socially in order to avoid the risks of spreading diseases such as HIV/AIDS. Because, as minorities as LGBT people in general and transgenders specifically may be, their exclusion and stigmatization because of their social or sexual transidentity can create major public health problems that can weaken the efforts of the health system, especially in developing countries. So, training of health workers in health issues specific to these minorities and in medical ethics is recommended.

Acknowledgements

Thanks to the actors who freely and knowingly agreed to participate in this study :

- Transgender people

- Public health care providers

- Humanitarian actors working on behalf of social and sexual minorities

Competing Interests

The author has no relevant financial or non-financial interests to disclose.

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Social Identity, Health Rights and Medical Ethics: An Analysis of the Attitudes of Caregivers of Public Health sector in the Medical Care of Transgender People in Côte d’Ivoire

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Version 1

Abstract

Introduction

Materials And Methods

Results

Stigmatizing attitudes

Denial of transgender care

Caregiver’s views on transgender people

Humiliation experienced by transgender people

Logics related to the attitudes of caregivers

Lack of professional awareness

Lack of training on gender and LGBT issues

Conflict between culture, caregiver’s religion and transgender people

Discussion

Health rights and LGBT stigmatization: what contradictions ?

Medical ethics and the stigmatization of LGBT people: What contradictions ?

Stigmatization of LGBT persons: what are the social implications ?

Conclusion

Declarations

References

Status:

Version 1