When Dr Sameera Mahamud Jahagirdar went through her forensic medicine and toxicology textbook during her graduation in medicine more than two decades ago, she was shocked. She learnt that homosexuality was described as a sexual deviation and was punishable as an offence. “Lesbianism”, “sodomy” and “transgenderism”, she learnt, were described in similar vein.
“It was very scary to read. It had a very negative impact on me. I would ask myself, ‘am I a diseased person?'”. It was only later, after she had graduated and after she was working at a college in Chennai, that she came across books describing homosexuality as normal.
A constant urge had set in in her mind by then to find out why medical textbooks in India pathologised homosexual and transgender people. It led her to work with an NGO named SAATHI, as a medical expert for a project called ‘Vistara’, reviewing medical textbooks. And soon, she found the root of the problem.
“We came to know that the textbooks draw their source from undergraduate curricula, which are wrong in themselves,” Dr Jahagirdar, currently pursuing super-specialisation training at NewHam University Hospital, London, said.
A brief history
The Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association (APA) is a reference book for psychiatric disorders and diseases. More than that, it is a benchmark to classify and define various mental illnesses. In its first edition, published in 1952, the DSM categorised homosexuality as a “sociopathic personality disturbance”.
By 1974, however, after protests and social mobilisation by gay and lesbian rights activists in the US, the APA removed ‘homosexuality’ from the DSM. But the battle was only half-won.
While DSM II removed homosexuality, it introduced a new diagnosis in its place called “sexual orientation disturbance”, replaced in DSM III by “ego-dystonic homosexuality (EDH)”, which referred to same-sex attraction that caused significant distress to a person.
But scholars persisted in their efforts to completely depathologise homosexuality, arguing that the logic of an EDH diagnosis suggested all identity questions that cause distress could be psychiatric disorders. “What about short people unhappy about their height?” they asked. “Why not ego-dystonic masturbation?”
Further progress was made in terminology and understanding of gender in general in the subsequent editions of the DSM. While DSM IV contained the term “gender identity disorder”, DSM V, released in 2013, replaced it with “gender dysphoria”, saying it is more descriptive than the previous term and “focuses on the clinical problem, not identity per se”. It described ‘gender dysphoria’ as the “distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender.”
All these advancements have contributed significantly towards depathologising homosexual people around the world. LGBTQ+ activists have used these arguments to confront and challenge discriminatory laws and push to be accepted in the wider society.
In India, after the erstwhile Medical Council of India (MCI) decided to review the country’s medical curriculum after more than two decades, it came up with the ‘Competency Based Undergraduate Curriculum for the Indian Medical Graduate’ in 2018. Stakeholders hoped that this curriculum would be more in sync with modern scientific beliefs and wouldn’t pathologise and stigmatise the LGBTQ community. But the MCI managed to spectacularly fail everyone’s expectations: “It was old wine in a new bottle,” Dr Jahagirdar said. “They changed the delivery of the content, but the actual content was never changed.”
Currently, for undergraduate students studying forensic medicine in India, the medical curriculum describes “sodomy”, “lesbianism” and oral sex as sexual offences, and “transvestism” (cross-dressing) as a “sexual perversion”. There is also no regard for consent and there are no discussions to this end.
In the psychiatry portions, under a topic called ‘psychosexual and gender identity disorders’, the curriculum says a student should be able to “enumerate and describe the magnitude and etiology of psychosexual and gender identity disorder”. ‘Gender identity disorder’ (GID) is an older term that has been used to describe transgender persons, but which experts are pulling back on today to depathologise it. The appropriate term today is gender incongruence, and it is not considered to be a disease or disorder.
However, gender incongruent persons often experience “discomfort or distress” arising from their “gender identity differing from their sex assigned at birth or sex-related physical characteristics” (source).
“This is called gender dysphoria,” Dr Aqsa Shaikh, an associate professor of community medicine at HIMSR, Jamia Hamdard, Delhi, and one of India’s first openly transgender doctors, said. One way to manage it is through gender affirmative therapy.
After the curriculum was published, Dr Jahagirdar, Dr Shaikh and two Supreme Court lawyers penned a letter describing the discrepancies in the curricula, along with updated scientific concepts. They intended to send it to the MCI.
For example, the letter said, “GID has been removed by WHO in ICD-11 with the recognition that it is not a disorder. It needs to be replaced with Gender Incongruence (as per ICD-11) or Gender Dysphoria (as per DSM-5).”
ICD stands for the ‘International Classification of Diseases’ manual published by the WHO.
Around this time, courtroom deliberations of Section 377 of the Indian Penal Code, which criminalised consensual homosexual acts between adults, were underway. The uncertainty at the time meant the authors didn’t eventually send their letter. Soon after, the Centre also scrapped the MCI board and replaced it with the National Medical Council (NMC).
This proved a setback for Dr Jahagirdar’s efforts. Faced with a new board, she had to start over.
Little economic incentive
In the meantime, thanks to the MCI’s lethargy, the textbooks in the market continue to retain medically outdated and socially stigmatising terms. For example, one psychiatry textbook lists ‘homosexuality’ under “other psychosexual disorders” and then notes the “essential features of ego-dystonic homosexuality”. It also retains the term ‘gender identity disorder’ and calls ‘transsexualism’ a “heterogenous disorder”.
Similarly, another textbook on the same subject lists ‘transsexualism’ as a “gender identity disorder” and ‘homosexuality’ is listed under “psychological and behavioural disorders associated with sexual development and maturation”. It also calls ‘ego-dystonic homosexuality’ a “disorder” when in fact the term is understood to be meaningless.
All these assertions go against modern scientific understanding of the underlying issues – as specified by DSM V and ICD 11.
The Indian Psychiatric Society issued a statement in 2018 saying homosexuality is not a disease and must not be regarded as such. In June 2020, it published a position statement reiterating its stand on the matter. When asked about the outdated content of the textbooks, the society’s current president P.K. Dalal said, “These books are very old. The change is occurring and it will gradually come up. It doesn’t matter what the curriculum or the books say; psychiatrists have seized of the matter.”
Books on forensic medicine and toxicology also list “sodomy” as a sexual offence without discussing or differentiating between consensual and non-consensual acts. But in their defence, it’s possible to argue that the Supreme Court struck down Section 377 only in 2018, which is fairly recent.
A marketing executive with a leading medical publishing house said medical books usually have a shelf-life of five years or so, depending on the subject. “Postgraduate entrance books, or books on those subjects that involve fast-changing technological advancements, are also updated regularly,”she said. “Forensic medicine and psychiatry are considered to be ‘short’ subjects carrying a lower percentage of the marks” in examinations.
As a result, according to her, there isn’t a sufficient economic incentive to regularly update the books on these subjects. “But it should be taken care of,” she said about content regarding queer-trans issues.
Gautam Biswas, an author of a text book on forensic medicine and toxicology, said the books should be updated to reflect the changes brought on by the Supreme Court judgement.
He called the new medical curriculum for forensic medicine “a copy-paste job” and said, “those who framed the curriculum are old-timers. We are also fed up with their job.”
“It makes a difference to the LGBTQ+ community.”
“The changes are being considered. You’ll have to wait to know when it is done,” Aruna Vannikar, head of the Undergraduate Medical Education Board, an autonomous body at the NMC, said.
However, she wasn’t clear about whether the board would consider inputs from the LGBTQ+ community. “Whatever will be good for the country and students will be done. NMC will go to the public,” said Vannikar. “The health ministry will also be involved. Everyone’s view will be considered.”
Dr Shaikh was clearer about the importance of these inputs, however: “‘Nothing about us without us’ is our motto when it comes to vulnerable groups. No framing of LGBTQIA competencies can be complete or representative without hearing the voices of those it concerns.”
In 2018, a study published by the Hong Kong Academy of Medicine, entitled ‘Attitude of Indian Medical Students Towards Homosexuality’, found that “about 15.9% of respondents believed that homosexuality was an illness; 24.8% considered homosexual [people] neurotic, 28.1% considered homosexual [people] promiscuous; and 8.2% thought that they posed a danger to children.”
The findings are alarming considering there more queer-trans persons will be coming in contact with the healthcare system in future. So there is a pressing need to ensure new generations of doctors are trained and sensitised to accommodate care-recipients’ needs.
Dr Jahagirdar said students need to be taught how to note the medical history of a person’s sexual life in a non-stigmatising way. “The core requirements of LGBTQ+ people with respect to the health domain needs to be taught.” And “if odd, abnormal content in the curriculum gets changed,” she added, “it will have a huge impact on the delivery of medical content to the new generation of doctors, and that will help the LGBTQ+ community at large.”
Editor’s note: The Wire Science thanks Sayantan Datta for their inputs and feedback on this article.
Adil Rashid is an independent journalist and has previously worked with Outlook. He tweets at @AdilRashid__.