LGBTQI+ Singaporeans face enduring stigma within healthcare

Stigma continues to prevail for lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) patients within the healthcare setting in Singapore, and this is partly due to the lack of training of medical students, a study has found.

Survey data involving 320 medical students from the three local medical schools showed that despite having moderately positive attitudes and comfort levels towards LGBTQI+ patients, the students had suboptimal levels of knowledge and preparedness with regard to treating or managing complex health-related issues that LGBTQI+ patients often deal with. [Med Educ Online 2023;28:2172744]

The median composite indices for attitudes, comfort, and preparedness were 3.30, 3.17, and 2.50, respectively. Only 12.19 percent of the respondents answered all 11 true–false questions about LGBTQI+ health correctly.

Singapore is viewed as an inherently non-LGBTQI-affirming society, with stigma occurring on multiple levels: cultural norms, discriminatory laws, and the lack of protective policies such as antidiscrimination laws. Indeed, the respondents themselves pointed out that the stigma against the LGBTQI+ community already existing in Singapore society has laid the groundwork for more stigma (whether anticipated or enacted) within the healthcare setting. 

One of the tangible consequences of such an issue is internalized stigma and care avoidance behaviour among LGBTQI+ patients, according to the investigators from the National University of Singapore, Singapore.

“Second, healthcare providers may adopt stigmatizing attitudes. Third, with a general climate that is not non-LGBTQI-affirming, healthcare institutions and professionals may become disinclined to be openly LGBTQI-affirming for fear of negative impressions among the wider public,” they added.

That said, LGBTQI+ patients may find it difficult to navigate care-seeking, which in turn lead to negative physical and mental health sequelae, the investigators noted. All these should serve as a call to action to a wider policy change in Singapore, its healthcare institutions, and its medical education system.

Battling stigma

Healthcare stigma towards LGBTQI+ patients is also seen elsewhere in the world. The findings of studies conducted internationally echo that of the local study: that health inequalities for LGBTQI+ patients occur due to an undercurrent of heterosexism and discrimination across levels ranging from healthcare institutions to the wider community. [Eur J Public Health 2019;29:974-980; Int J Health Serv 2020;50:44-61]

Furthermore, in a study in New England in US, more than half of the 658 medical students surveyed also reported inadequate preparation to serve LGBTQI+ patients, with the overall self-reported confidence levels to treat LGBTQI+ patients being limited and the overall self-reported comfort levels being moderate. [Med Educ Online 2018;23:1461513]

A lot can be done to address the stigma concern in healthcare and beyond. In the present study, the respondents offered a few suggestions. First, LGBTQI+ health content should be integrated more subtly and holistically into the local medical curriculum rather than as a stand-alone module or topic. Sensitivity, empathy, and professionalism should also be practised in order to keep personal views and clinical care separate. Finally, safe spaces can be created for patients at public healthcare institutions or for queer-affirming healthcare providers to come together, network, and improve the queer-affirming healthcare scene.

“A thorough understanding of how stigma operates throughout healthcare is key in improving the system through structural means (eg, organizational culture and quality of care standards), interpersonal means (eg, doctor-patient relationships and attitudes of healthcare providers), and intrapersonal means (eg, self-stigma and care avoidance or nondisclosure),” the investigators pointed out. [Health Manage Forum 2017;30:111-116]

“Training in LGBTQI+ health would be especially beneficial in a Singapore context wherein LGBTQI+ health disparities are present, and LGBTQI+ health is not presently well-addressed in medical education syllabuses,” they added.

Overall, this study provides an evidence base to support the development of and guide future interventions to reduce stigma and improve the healthcare professionals’ capabilities in caring for LGBTQI+ patients in Singapore, according to the investigators.