1. Attitudes of General Practitioners Toward Homosexuals in the Netherlands Antilles Anita Radix MD MPH Gerard van Osch MD Carl Buncamper AIDS SUPPORT GROUP Saba

2. PAHO – On Homophobia in Healthcare “Homophobia in the health services in the (Latin America & Caribbean) region is widely reported but the extent to which it is a factor in HIV/AIDS-related discrimination has not been statistically researched” Such research is essential in the construction of an appropriate response to stigma and discrimination

4. How the Study started HIV prevalence in the Netherlands Antilles is 2.5% and rising HIV prevalence in the Netherlands Antilles is 2.5% and rising The current understanding in the Caribbean is that HIV transmission is mainly heterosexual - majority of programs have therefore been based on this assumption The current understanding in the Caribbean is that HIV transmission is mainly heterosexual - majority of programs have therefore been based on this assumption No government funded programs specifically directed at MSM exist in the Netherlands Antilles No government funded programs specifically directed at MSM exist in the Netherlands Antilles

5. But.. Data from CAREC indicate records of risk activity for PLWHAs are incomplete Data from CAREC indicate records of risk activity for PLWHAs are incomplete ADC laboratory statistics in Curacao suggest HIV prevalence in men is 3X that of women ADC laboratory statistics in Curacao suggest HIV prevalence in men is 3X that of women Data from Saba, St. Eustatius and St. Maarten show MSM transmission is still important Data from Saba, St. Eustatius and St. Maarten show MSM transmission is still important (PLWHAs in St. Maarten 18% MSM, Saba 50% MSM) (PLWHAs in St. Maarten 18% MSM, Saba 50% MSM)

6. Gender Distribution of Reported Adult AIDS Cases 1982 – 1998 CARICOM member countries (CAREC) 67% Male 33% Female M:F ratio = 2:1

7. Categories of Transmission in Reported AIDS Cases in CMC: 1982-2000 Heterosexual 64% Unknown 17% MSM 11%

8. Categories of transmission in men Jamaica 1998 (CAREC) ??? 47% 46% 7%

9. HIV incidence per 1000 tested ADC-LAB Curacao, Netherlands Antilles Epidemiology & Research Unit Curaçao

10. Why are homosexual/bisexual men not disclosing their sexual orientation? Institutionalized homophobia as evident in popular reggae/dancehall lyrics - “Chi chi man”, “Bun out di chi chi” “Log on” Institutionalized homophobia as evident in popular reggae/dancehall lyrics - “Chi chi man”, “Bun out di chi chi” “Log on” Legislation in many Caribbean islands criminalizes homosexual activity Legislation in many Caribbean islands criminalizes homosexual activity e.g. CARICOM Model Legislation - allows for 5 year prison sentence for "gross indecency“. The law clearly states that heterosexual couples are exempted

11. And…what about the role of the healthcare providers? Do healthcare providers in the Caribbean contribute to nondisclosure of sexual orientation by way of their Homophobia & Heterosexism?

12. Impact of Nondisclosure “…unrecognized homosexuality by the physician or the patient’s reluctance to report his or her sexual orientation can lead to failure to screen, diagnose, or treat important medical problems.” “…unrecognized homosexuality by the physician or the patient’s reluctance to report his or her sexual orientation can lead to failure to screen, diagnose, or treat important medical problems.” Journal of the American Medical Association, Report 8 of the Council of Scientific Affairs, 1996

13. Homophobia in the Healthcare System 87% gay, lesbian and bisexual Ontarians had been discriminated against within the health care system 87% gay, lesbian and bisexual Ontarians had been discriminated against within the health care system 70% had been insulted on the basis of their sexual orientation 70% had been insulted on the basis of their sexual orientation (Project Affirmation, Coalition for Lesbian and Gay Rights in Ontario, Toronto: unpublished data, 1995)

14. GLMA Study 67% of surveyed physicians report knowledge of substandard care or denial of care to gay and lesbian patients 67% of surveyed physicians report knowledge of substandard care or denial of care to gay and lesbian patients 64% believe patients risk their quality of care by “coming out.” 64% believe patients risk their quality of care by “coming out.” 1994 Gay and Lesbian Medical Association (GLMA) survey, "Anti-gay Discrimination in Medicine,"

15. The American Medical Association in 1991 reported that: 35% of general practitioners and internists feel nervous around gay people. 35% of general practitioners and internists feel nervous around gay people. 35% felt that homosexuality is a threat to many of our basic social institutions. 35% felt that homosexuality is a threat to many of our basic social institutions.

16. Study Question Does a high level of homophobia/ heterosexism exist amongst general practitioners in the Caribbean? Could this contribute to an atmosphere that prohibits disclosure of risk behaviour by their patients?

17. Investigation Focus groups with Gay men and lesbians in the Netherlands Antilles Focus groups with Gay men and lesbians in the Netherlands Antilles Questionnaire to General Practitioners in the Windward islands to gauge level of homophobia Questionnaire to General Practitioners in the Windward islands to gauge level of homophobia

18. Focus Group Questions 1. Have you ever had a homophobic encounter with a physician or other healthcare provider? 2. Would you feel comfortable coming out to your healthcare provider? 3. Are you comfortable requesting advice on gay related health issues from your health care provider? 4. Has your physician or healthcare provider ever asked you about your sexual orientation? If so, did you perceive any discomfort on their part? 5. Do you think that a homophobic physician can provide appropriate healthcare to lesbian and gay patients. If not, list some reasons.

19. Results from Focus Groups 80% had never been questioned about their sexual orientation by their GPs 80% had never been questioned about their sexual orientation by their GPs 73% stated that they did not think that a homophobic physician could provide appropriate healthcare to G&L patients and would not disclose homosexuality- because: Improper advice may be given Improper advice may be given Couldn’t give good care if homophobic Couldn’t give good care if homophobic Drs may purposely undertreat/ delay treatment “doing God’s will” Drs may purposely undertreat/ delay treatment “doing God’s will” Would not understand psychosexual issues/ not supportive Would not understand psychosexual issues/ not supportive Discomfort around Gays would prevent proper care Discomfort around Gays would prevent proper care

20. GP Study In November 2003, all GPs were contacted in St. Maarten, St. Eustatius and Saba. In November 2003, all GPs were contacted in St. Maarten, St. Eustatius and Saba. Questions included “The Index of Attitudes towards Homosexuality” (Hudson and Ricketts, 1980) as well as 1 question from the International Social Survey Program 1998/1999 Questions included “The Index of Attitudes towards Homosexuality” (Hudson and Ricketts, 1980) as well as 1 question from the International Social Survey Program 1998/1999 Demographic data collected included gender, age, country of medical training & nationality Demographic data collected included gender, age, country of medical training & nationality

21. ISSP 1998-1999 International Social Survey Program’s ISSP 1998-1999 Do you think it is wrong or not wrong … sexual relations between two adults of the same sex? Not wrong at all [100 points] Wrong only sometimes [67 points] Almost always wrong [33 points] Always wrong [0 points]

22. Index of Attitudes to Homosexuality Hudson & Ricketts, 1980 25-item scale designed to measure individuals' affective responses toward gay men & lesbians. 25-item scale designed to measure individuals' affective responses toward gay men & lesbians. IHP uses a Likert-type response format from 1 = strongly agree to 5 = strongly disagree. IHP uses a Likert-type response format from 1 = strongly agree to 5 = strongly disagree. Total scores range from 0 to 100, with higher scores indicating greater homophobia Total scores range from 0 to 100, with higher scores indicating greater homophobia Score from 0 to 25 high grade non-homophobics 26 and 50 low grade non-homophobics 51 and 75 low grade homophobics >76 high grade homophobics

23. Results 20/22 General practitioners participated (91% response rate) 20/22 General practitioners participated (91% response rate) Age range 32 to 56, average 44.8 Age range 32 to 56, average 44.8 20% women 20% women 30% Caribbean born, 60% EU, 5% Africa & Asia 30% Caribbean born, 60% EU, 5% Africa & Asia

24. Results cont. No significant association between age and scores noted No gender differences noted No differences in country of medical study (most Dutch Antillian GPs receive medical training in The Netherlands) Large differences in response rates by country of birth (Caribbean vs. other)

25. Results (Index Attitudes to Homosexuality) Lower scores on this scale reflect more tolerant attitudes to homosexuals Lower scores on this scale reflect more tolerant attitudes to homosexuals Caribbean-born doctors had average score of 54.2, non-Caribbean born doctors scored 29 (p<.004) Caribbean-born doctors had average score of 54.2, non-Caribbean born doctors scored 29 (p<.004) 67% Caribbean born physicians had scores in homophobic range c/w only 14% non-Caribbean born (Dutch/EU) 67% Caribbean born physicians had scores in homophobic range c/w only 14% non-Caribbean born (Dutch/EU)

26. Results (ISSP) Higher scores on this scale reflect more positive attitudes to homosexuals Higher scores on this scale reflect more positive attitudes to homosexuals Caribbean-born doctors had average score of 19.8, non-Caribbean born doctors 71.4 (p=0.016) Caribbean-born doctors had average score of 19.8, non-Caribbean born doctors 71.4 (p=0.016) A high correlation was noted between individual scores on the ISSP and IAH scales (r=0.79) A high correlation was noted between individual scores on the ISSP and IAH scales (r=0.79)

27. Tolerance Scores (ISSP) 1. Netherlands77 2. DUTCH/EU born GPs71 3. Switzerland62 4. Denmark60 5. Spain59 6. Sweden57 7. Germany W56 8. Norway54 9. Czech53 10. Austria52 11. France51 12. Germany E51 13. Great Britain46 14. New Zealand41 15. Australia41 16. Slovenia34 17. Slovakia33 18. Italy32 19. USA31 20. Ireland29 21. Japan28 22. Russia27 23. Cyprus26 24. Latvia26 25. Northern Ireland25 26. Hungary23 27. Portugal21 28. Bulgaria21 29. CARIBBEAN born GPS20 30. Chile9 31. Phillipines8

28. Conclusions Nondisclosure of homosexual activity exists as evident by Nondisclosure of homosexual activity exists as evident by 1. high numbers of HIV+ men with “unknown risk factors” and 2. higher sex ratio men : women Physicians in the Caribbean may contribute to the problem by their homophobic attitudes Physicians in the Caribbean may contribute to the problem by their homophobic attitudes Fear of discrimination by healthcare providers is an important factor preventing disclosure by MSM Fear of discrimination by healthcare providers is an important factor preventing disclosure by MSM

29. Barriers to Healthcare for GLBT Discrimination - Anticipated, perceived, or actual discrimination by health care provider based on sexual identity/ behavior Discrimination - Anticipated, perceived, or actual discrimination by health care provider based on sexual identity/ behavior Exclusion – Perceived exclusion from health promotion campaigns. Exclusion – Perceived exclusion from health promotion campaigns. Fear - Disclosure of sexual orientation may lead to criminal charges; substandard or refusal of health care Fear - Disclosure of sexual orientation may lead to criminal charges; substandard or refusal of health care

30. What can be done? Greater awareness that a significant factor driving the HIV epidemic in the Caribbean is stigma and discrimination against MSM Greater awareness that a significant factor driving the HIV epidemic in the Caribbean is stigma and discrimination against MSM Informed and open discussions regarding sexuality are needed Informed and open discussions regarding sexuality are needed A call for legislation guaranteeing equal protection for GLBT persons A call for legislation guaranteeing equal protection for GLBT persons Funding agencies should require inclusion of programs that prioritize reduction of MSM transmission in the Caribbean Funding agencies should require inclusion of programs that prioritize reduction of MSM transmission in the Caribbean

31. The failure of programs to specifically address risk reduction in MSM, despite the evidence that this is clearly an important factor in the Caribbean HIV epidemic is itself indicative of homophobia and heterosexism within the healthcare profession The failure of programs to specifically address risk reduction in MSM, despite the evidence that this is clearly an important factor in the Caribbean HIV epidemic is itself indicative of homophobia and heterosexism within the healthcare profession AIDS SUPPORT GROUP Saba

32. Thank You Saba, Netherlands Antilles