Gender identity: challenges to access social and health care services for lesbians in Nepal

Literature about same-sex love and sexuality in Nepal is rare. However, limited anecdotal evidence on these issues signals that the health and social care needs of lesbians in Nepal are high. This qualitative study explores the challenges faced by lesbians in Nepal in accessing health and social services. In-depth interviews carried out with fifteen lesbians found that Nepalese lesbians face many challenges from families and society which result in a stressful life, homelessness and forced and unwanted relationships and marriage, including self-harming behaviours. They often face discrimination and harassment when coming out at public administration and social institutions. Hence, most lesbians of Nepal prefer not to disclose their sexual identity due to the fear of becoming isolated and not getting quality health care services.


Background
Nepal has a patriarchal society where women are always considered to be second to men (Thapa-Oli et al. 2009).Women are seldom in a decision-making position in the family (Acharya et al. 2010).Life expectancy at birth for a female was always less than her male counterpart; however this has changed only since 2004 (WHO 2005).Nepali people have many strong traditional norms and beliefs on sex and sexuality (Mahat and Scoloveno 2001).Open discussion regarding sexual and reproductive health issues is still a social taboo (Simkhada et al. 2010).However, males are sometimes excused when talking about sex (Regmi et al. 2010).Sexual minorities i.e.Lesbian Gay Bisexual Transgender -LGBT (Ullerstam 1967) have only very recently been recognized at government level and are yet be socialized in Nepal.In spite of instances of same-sex love and sexuality within almost all ancient civilizations (Vanggaard 1972) sex and sexuality issues are not widely accepted in Nepal (Dahal 2008).However, public acknowledgement of 'sexual minorities' is very recent in Nepal.Indeed, there are only a few organisations working in the field of sexual minority issues in Nepal and the Blue Diamond Society (BDS), a non-governmental organization, is spearheading this.BDS has already established networks in more than 20 municipalities/districts in Nepal.Actual facts and figures regarding the situation of lesbians in Nepal are rare; however, there are estimated to be 1,200 lesbians in Nepal (BDS 2008).
BDS contributed to the legalization of sexual minority issues by demanding protection of their legal rights in a petition for a verdict of the Supreme Court of Nepal.Their demands were threefold: to recognize the civil rights of transgender people without requiring them to renounce one gender identity for another; to create a new law preventing discrimination and violence against LGBT communities; and to require the state to make reparations to LGBT victims of state violence and/or discrimination.This petition was premised on the unique relationship between Nepal's Supreme Court and its legislature.In response to a request by BDS for legal observers to be present at the hearing, the International Gay and Lesbian Human Rights Commission (IGLHRC) commissioned a team of lawyers from India, to serve as court observers and share legal strategy with BDS legal counsel.Their report outlines the history behind the proactive litigation by LGBT groups in Nepal and provides legal analysis proceedings, which includes some precedent-setting remarks by the Court (Divan 2007).In this way, Nepal's Supreme Court ruled in favour of laws to guarantee full rights to sexual minorities, and all gender minorities have been defined as "natural persons".The Government of Nepal has also given consent to same-sex marriages (Narayanan 2008).
The only organization (non-governmental) in Nepal which works to improve the sexual health, human rights and well-being of lesbians is Mitini Nepal, although only a small number of lesbians have registered with this organization so far.Literature about discrimination, sexual abuse, social harassment and lack of access to public services by lesbians is also rare in the context of Nepal.Given this limited information, the health and social care needs of lesbians in Nepal are relatively still unknown.
It is generally recognized that lesbians suffer from depression, low self-esteem and social ostracism.Biaggio (1997) argued that lesbianism provokes confusion and uncertainty (for the women concerned) about how to address its consequences.Therefore, they are forced to lead a split life or dual existence.There is also evidence that lack of legislation and action by governments of Nepal to protect lesbians have resulted in many instances of abuse and discrimination (Mitini Nepal 2007).For example, if the lesbian woman is from a so-called 'low caste' ethnic group, she has to face triple discrimination -(1) as a woman, (2) as a low caste and (3) as a sexual minority (BDS 2008).
The aim of this qualitative study is to explore the challenges in accessing social and health care services by lesbians in Nepal.It is anticipated that the issues discussed in this paper would be beneficial in designing policies and programmes to address the specific needs of lesbians living in Nepal accordingly.

Study design and procedure
The study approach was an exploratory qualitative study.It is now widely accepted that qualitative methods are commonly used in health and social sciences (Flick 1998) and recommended for research on sexuality and other sensitive issues (Reid andvan Teijlingen 2006, Silverman 2006).Previously this approach has been used to research sexuality and sensitive issues in Nepal (e.g.Puri & Busza 2004, Simkhada et al. 2010, Regmi et al. 2010).
In the summer of 2008, we carried out fifteen in-depth interviews with lesbians of Mitini Nepal.These participants were purposively selected.Interviews were conducted in an environment in which the respondent felt most comfortable, where they could freely discuss the issue.A semi-structured discussion guide was Vol. 2, No. 2; October 2010 Published by Canadian Center of Science and Education 209 developed in the Nepali language and tested with two lesbians.The guide consisted of a number of issues around socio-economic and cultural challenges, health problems, access to public services and places and access to health care.All interviews were conducted by a skilled researcher.They were tape recorded with the permission of the participants and generally lasted one to two hours.The participant was given priority to choose the location for the interview.On all occasions, appointments were made in advance.

Data management and analysis
We carefully made all transcriptions based on the original tape recordings.The first author translated all transcriptions into English.The translated version was cross-checked to ensure the inter-rater reliability.Any disagreements were discussed in detail between the authors for appropriate translation.Data were cleaned and coded prior to analysis.The first author analysed all transcripts and the other authors acted as second coders.A thematic approach was followed in the analysis and relevant quotes are presented to illustrate the key themes.

Ethics consideration
Ethics approval was granted from the Nepal Health Research Council (NHRC).Similarly, an official letter was submitted to Mitini Nepal and Blue Diamond Society (BDS) regarding this research work.Before fixing the date for the in-depth interviews, suggestions and permission were sought from the concerned authority so as to avoid any disturbances and to increase participation.Consent was taken from participants prior to the study.Confidentiality was maintained by avoiding using the names of the participants where necessary.The rights of the participants were kept in consideration (to know our objectives, freedom to respond and decline etc).

Participants
Out of fifteen participants, seven had lived or were living in a rural area and eight lived in Kathmandu (the capital city of Nepal).Most rural participants were of the age group 25-29 years, whereas the majority of the urban participants were between 20-24 years of age.Most respondents are of Newar and Janajati (Rai/ Limbu/ Magar) ethnic background.As lesbian marriage had not been legalized in Nepal prior to this research, most of the participants reported themselves as unmarried although they were currently living with their partners.Only half of those from the rural areas had received some secondary education, whereas most urban participants had received secondary education (Table 1).
The following themes were identified: (1) socio-economic and cultural challenges; (2) health problems; (3) challenges to access public services and places; (4) access to health care.

Socio-economic and cultural challenges
Most of the rural respondents reported that it is difficult to disclose oneself as a lesbian in the community.Some participants indicated they were unaware about their sexual identity during their childhood and when of school age.Others talked about learning about their identity while they were in school, which included gender issues such as discrimination and injustice although none of them reported it to their family members and teachers.Some also believed that they only shared it with their close friends.They also believed that it has been easier for them to disclose their lesbian identity since the legalisation of lesbians in Nepal in 2007 (AD).However, it was commonly agreed that it is still a matter of concern and risks them being isolated and discriminated against, if their sexual identity is disclosed to their teachers and colleagues.For example: I always used to dress like a boy, since childhood.I knew that I was a lesbian when I was studying in class eight.I used to love a girl at that time.I always used to think why did I fall in love with a girl.My best friend was also a lesbian.When the teacher found out that she was a lesbian she was thrown out of the school (IIP11, Rural Participant).
My gender is female but I look like a male, having the sexuality of a male.So it's really difficult to come out in the village.I don't have any problems coming out as a lesbian to my village friends but some of them say "why do you get dressed up like this? (IIP9, Rural Participant).
Although some participants argued that it is often difficult to disclose one's identity as a lesbian, they further asserted they don't hesitate to introduce themselves as lesbians in some circumstances.Surprisingly, some explained that they felt it pleasant to be known as lesbians or female homosexuals.
While observing the social relationships in rural settings the lesbians were found to be socially and emotionally distant from their family and relatives.Some lesbians have been in a relationship with their partners lasting for more than ten years, regardless of the social and cultural acceptability of their marriage.This was particularly observed in urban areas.Most of the participants stated that they rarely go to their (parents') home for fear of being ISSN 1916-9736 E-ISSN 1916-9744 210 forced to get married, which often results in a dispute among family members.They also revealed that when the parents discover their daughter to be a lesbian, they force her to get married to a man and live in a heterosexual relationship.The participants also shared that parents and family members even attempt to separate them from their partners, causing them further problems.For example, a lesbian explained her long story as: I had my best friend partner named Sandhaya (name changed).My family found out about our relationship and forcefully married me off.When Sandhya found out that I was married she used to walk the streets of Thamel like a mad woman.I also did not have a good relationship with my husband and after one year I went to Blue Diamond Society [BDS] with my children and my husband.We told BDS everything about our relationship and how we got married.My husband also said that I was not happy with him.BDS suggested that we separate and also mentioned about the legal procedures.After our divorce my husband took my children with him.After a couple of months, I had a heart problem.I tried to tell Sandhaya my problems but it was useless, she was already into drugs.She always injects, two to three times a day.Anyway, I was supported by Mitini Nepal and BDS for my treatment.I recovered and after a couple of months, I went to visit Sandhaya but she had already died due to excessive intravenous drug use (IIP2, Urban participant).
Most of the participants commonly agreed that lesbians are always harassed verbally (using slang words) in public places like parks, social gatherings, hotels, minibuses etc. in the city, which is always embarrassing.
People tease and make fun of us.We have to face unnecessary psychological torture.Seeing the situation, sometimes we make them aware that we are also part of this society.We talk about our rights (IIP8, Urban Participant).
Most of the participants also reported economic problems related to their status.They also revealed that they were expelled from their jobs due to their sexual identity which led them to joblessness.For example: I joined one of the security forces and was working as an instructor during my work period.I was also given leadership and discipline awards from them.The bad incident happened in my life … I was sacked and kept in custody saying that I was involved in unnatural sexual activities.The crime that I committed was that I was a lesbian in Nepal.I was kept in a dark room where there was no water, no sunlight.I was unconscious for a long time (IIP6, Urban Participant).
The participants stressed that training for jobs such as security guard, driving and handicrafts work for them because they could be self-employed and can make a living.

Common health problems
Participants recounted that lesbians in Nepal are facing many health-related problems.Rural participants reported that some of them also suffer from Tuberculosis (TB) as they mostly work as manual labourers.Other health and psychological problems such as depression, sleeplessness and loneliness were also frequently reported by urban participants.They claimed that lesbians face such psychological disorders due to discrimination and social harassment from the community.
When we are excluded from our family and society, we get hurt emotionally.Some even take wrong decisions...We feel that our sexuality was a curse.Some even take various hormones without a doctor's prescription; they can have negative consequences (II14, Rural Participant).
Our participants also have a belief that sexually transmitted infections (STIs) are also common among lesbians.Most reported discharge of white liquid from the vagina, itchiness in the genital organs, poor hygiene and lower abdominal pains.In addition to the aforementioned psychological disorders, some of the sexual health related problems were also reported by them.

During sexual contact my partner always has a white liquid vaginal discharge, which has a foul smell. She takes a bath twice a day but my partner feels uncomfortable about going to the health post (IIP13, Rural Participant).
Nevertheless, the lesbians of masculine appearance reported that they face more of such problems than their more feminine-looking counterparts.

Challenges to access public services and places
Lesbians from rural areas reported that they face difficulties in accessing and getting administrative services from local level public service offices.Participants frequently revealed that the village level authorities were not well organised; therefore problems arise when their identification is required for verification purposes, i.e. matching their photographs against their actual appearance.Participants also mentioned that similar problems exist in banks where they perceived they were asked more questions than others to gain access to banking services.They also face inconvenience during formal procedures for obtaining a citizenship certificate and similar formalities, illustrated by these quotes: In public places such as the village development community, health posts, locally generated banks etc, if the offices know our identity they will start hating us and even refuse our requests (IIP15, Rural Participant).
Recently when I went to register my land ownership certificate with my father, the government officials said that I was not the daughter of my father.I really cried a lot (IIP2, Urban Participant).
Similarly, our study also found that lesbians face many problems while travelling.They are questioned, for security reasons, in the airports as their passport photos do not always exactly match their appearance, illustrated here: I was flying from Kathmandu to Thailand to take part in a HIV/AIDS conference; it was really difficult for me to convince the security guard that I was the right person travelling since my passport photo did not match my appearance (IIP1, Participant).
Some of the participants found using toilet facilities in public places to be problematic and some do not feel comfortable using both male and female toilets in public places, described here: The most difficult problem that I faced was going to the public toilets.I look like a man but I am biologically a female.If we go to the female toilets the women scold us a lot (IIP4, Urban Participant).
Surprisingly, most lesbians shared that they rarely face any discrimination in religious places like temples, churches and monasteries.None of our participants had problems going to religious places such as temples, monasteries, churches etc in the district; however, some described difficulty in choosing the queue to use to go into the temple, highlighted by this example: When I go to the temple there are always two different queues to worship -one men's and the other women's; we cannot stay in the ladies' line but we don't want to go to the males' either.It's good if we can have our own line such as a third gender line (IIP9, Rural Participant).
It was also commonly agreed among participants that when their identity is exposed it often brings detrimental outcomes.For example, one participant shared her story as: I and Laxmi (name changed) were the first exposed lesbian couple in Nepal.We came out from different Medias.
The greatest problem that we faced was that we were told to leave the flat where we were staying in the community and we were also denied the opportunity to live in a good apartment.They used to kick us out, accusing us of influencing their daughters and creating social evils.We moved apartment 15 or 16 times due to our sexual identity (IIP2, Urban Participant).

Access to health care
Study participants described that they never come out as lesbians to the doctors/physicians in health facilities (e.g.health posts and district hospital).They believed that they may not be treated well and that their illnesses will remain unsolved if they are identified as lesbians.Most of them wanted to consult a female doctor/physician even though they really wanted to have access to a sexual minority's specialist doctor/physician.Almost all of the participants perceived that protecting patient confidentiality was poorly practiced in health service centres, illustrated here: Doctors and nurses don't keep confidentiality... if we say that we are lesbians, I think that they will discriminate against us since they are not emotionally and culturally distanced from the Nepalese culture and society (IIP7, Urban Participant).
Doctors were commonly perceived to regularly discriminate against those who took part in this study on the basis of their sexuality and identity.
Our participants 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 do 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, exemplified by these quotes: We feel it's very difficult to access health care facilities.We are biologically female but some look like a male...it becomes more difficult.Some have a generally male outlook but while filling hospital forms they have to write female.This also creates debates.Also we cannot share our problems easily.Either we are compelled to hide our health-related problems or have to solve them by consulting peer groups (IIP5, Urban Participant).
In the district hospitals, the administrative staffs don't know which ward to admit us to.They say how can we love those people who look like hijada [called half-male and half-female] and don't have any identification?They should have married and lived like women (IIP15, Rural Participant).
Surprisingly, it was also found that some participants even use another person's identity asking for medicine so that they will not be identified in the society by the doctor used to prescribe it, for example: I had rashes on my genital organs…but I told the doctor that one of our relatives has rashes on her genital organs.
When the doctor said that it needs to be checked, I was very scared in case the doctor asked my marital status, identity and sexuality.I convinced the doctor that my relative could not come due to her household works, and then the doctor prescribed the medicine (IIP9, Rural Participant).

Discussion
This study explored issues around socio-economic and cultural challenges, access to public and health services, health behaviours and challenges.It is unique and the first of its kind in attempting to draw a clearer picture of the perception and experience of lesbians relating to their day-to-day life in Nepalese society.
Most of the study participants reported less discrimination in religious places like temples, churches and monasteries, compared to that in public and administrative places such as airports, government offices and public toilets.These problems usually arise when their appearance does not exactly match their identity documents.They are harassed and teased in places such as parks, cafeterias, hotels and minibuses.Indeed, social exclusion and discrimination may bring many psychological disorders for lesbians.For example, a previous study documented that lesbians suffer from common psychological disorders such as anger, depression, sleeplessness, nightmares, flashbacks, sleeping disorders and uncontrollable crying (Quiery 2002.)However, there is also evidence that sexual-minority people also address these issues such as abuse, harassment and inequalities in four ways; (1) avoiding or ignoring them, (2) tolerating to optimal stage, (3) relying on someone else and (4) rebelling against these activities (Pendragon 2010).However, our study did not collect any information regarding strategies used by lesbians to avoid these situations.
Our study found that most lesbians in Nepal cannot easily disclose their sexual identity as there is a fear of exclusion.Indeed, this has also resulted in lesbians' low participation in education, particularly in most rural areas.Perhaps there is a fear of harassment and isolation from their peers in their schools.A study carried out in New Zealand also found hostile educational environments in school.This study also reported that there is also harassment of students attracted to their own gender (Semlyen et al. 2008).Our findings also suggest that there is a possibility of students leaving their parental home in order to avoid these circumstances.They are usually pushed into heterosexual marriage if their family members suspect they are interested in same gender relationships.However, the government of Nepal now has given consent to same-sex marriage.A previous study also showed that forced marriage led lesbians and gays to run away from home and the number of homeless youths (Lesbian and Gays) had reached 3,200,000 from 115,000 (Ray 2006).
Although the relationship between a sexual minority identity and risky sexual relationships with opposite sex partners is yet another issue of research (Herrick 2010), most participants in this study have a belief that lesbians often engage in risky sexual behaviour.They are also reluctant to utilize existing health care information and services.It can be argued that they are not able to disclose their sexual issues to the health services providers.
Previously, it has also been reported that discrimination and abuse are the main causes of inhibiting people from accessing health services (Mulligan 2005).This also highlights that health facilities have also failed to provide lesbians with specialised sexual and reproductive health education and services.Perhaps mass media would be a possible means of disseminating sexual health information to these groups.In addition, provision of health care providers from sexual minorities and establishment of friendly service centres in convenient places would encourage them to utilize sexual and reproductive health services.
Although there is a general view that talking about sensitive issues with sexual minorities is difficult, most participants in this study actively discussed them.This highlights the impact of mass media.In addition, provision of skilled researchers and assuring confidentiality to the participants might have contributed to getting a better response from them.This study was carried out in one district of Nepal; hence our findings may not be generalized to the other areas of Nepal.Nevertheless, the most important outcome of this study is the "voice" of Nepalese lesbians which we have attempted to document.
The study highlighted lesbian health and social issues in Nepal.Valuable experience and perception of lesbian day to day living was explored.There was difficulty in projecting the realistic figure of lesbians in Nepal.The lesbians of Nepal had difficulty in coming out (sharing their feelings), which could be due to fear of isolation from society.Finally, the key strength of this paper is that it reports on research which is the first of its kind in Nepal.

Conclusion and recommendations for research and practice
It is imperative from this study that the magnitude of problems faced by Nepalese lesbians need to be quantified alongside the in-depth information provided by this study in order to categorise some of the social, economic and public health aspects.This will give an elucidated situation-analysis for better utilisation of the information in policies and programmes.This recommendation has been put forward because the extent of socio-economic and health-related problems of the sexual minority population is an emergent issue and requires greater efforts to tackle it.Since the non-governmental sector has already been involved in this field, better networking with government bodies could be vital for synergistic results.Further research is required to present the situation of each of the issues such as inequalities in education, employment, mental health, sexual health and other illnesses raised in this study.Following this, strategies must be developed and implemented in order to address each of these issues.
There is an urgent need to accurately determine the number of lesbians in Nepal in order to make plans and policies to address their basic needs.The study brings to light the impact of social exclusion on lesbians in Nepal.It is important to be aware of the major challenges faced while living as a lesbian in Nepal and the aspects of their lives that could be improved.