Lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI+) healthcare in Singapore: perspectives of non-governmental organisations and clinical year medical students

Figures & data

Table 1. Overview of organisations interviewed in qualitative component of the study.

Organisation’s focus	Type of organisation	Role in organisation	Reference number
LBTQ women	Non-governmental organisation	Programme manager	001
General LGBTQI+ community	Non-governmental organisation	Programme leader	002
Sexual health of the LGBTQI+ community	Non-governmental organisation	Programme leader	003
Religious LGBTQI+ individuals	Queer-affirming religious organisation	Programme leader	004
General LGBTQI+ community	Queer-affirming commercial entity	Programme leader	005
Trauma survivors who are LGBTQI+	Queer-affirming social enterprise for trauma recovery	Programme leader	006
Transgender community	Non-governmental organisation	Community worker	007
Transgender community	Non-governmental organisation	Member	008
General LGBTQI+ community	Community group	Member	009
University-based LGBTQI+ community	University-based organisation	Programme leader	010
General LGBTQI+ community	Non-governmental organisation	Member	011
Bisexual individuals	Community group	Programme leader	012
LGBTQI+ youth	Queer-affirming youth community group	Programme leader	013

Table 2. Descriptive statistics from quantitative component of the study (n = 320).

Demographic Variables	n/Mean	Percentage/S.D.
Gender
Male	151	47.19
Female	167	52.19
Others	2	0.63
Medical school
Medical school 1	191	59.69
Medical school 2	98	30.63
Medical school 3	31	9.69
Year of Study
First clinical year	138	43.13
Second clinical year	115	35.94
Third clinical year	67	20.94
Religion
Agnosticism/atheism/no religion	143	44.69
Christianity	118	36.88
Islam	3	0.94
Buddhism	36	11.25
Hinduism	14	4.38
Sikhism	1	0.31
Taoism	5	1.56
Identifies as LGBTQI+
No	282	88.13
Yes	38	11.88
Knows of anyone who is LGBTQI+
No	41	12.81
Yes	279	87.19
Closeness to LGBTQI+ contact1 (n = 279)2	7	3, 8
Relationship to LGBTQI+ contact (n = 279)2
Acquaintance	40	14.34
Colleague	23	8.24
Friend	194	69.53
Partner	15	5.38
Relative	7	2.51
Identifies as an ally (n = 282)3
Yes	137	48.58
No	48	17.02
Unsure	70	24.82
Prefers not to say	27	9.57
Composite attitudes score4	3.21	0.367
Composite knowledge score4	7.91	2.27
Composite preparedness score4	2.50	0.732
Composite comfort score4	3.20	0.571
Composite perceived importance score4	3.38	0.541
Perception of adequacy for curricular coverage of LGBTQI+ health issues4	1.74	0.738

¹– Median with composite values.

²– only answered by those who know someone who is LGBTQI+.

³– only answered by those who do not identify as LGBTQI+ themselves.

⁴– reporting mean and standard deviation instead of frequency and percentage.

Table 3. Sub-theme 1: Singapore as a non-queer-affirming society to live in from the outset.

Subtheme	Quote	Interview reference number
Care avoidance due to perceptions that providers would be discriminatory	‘So the lack of societal understanding would cultivate a hostile society in general, which leads into a lack of understanding of healthcare providers … we can speculate that they (people who did not disclose their sexuality to doctors in a series of interviews done by the organisation) were either not comfortable due to environment, you know, societal stigma at large, or, and or like the perception that the provider would be discriminatory … ’ ‘The lack of anti-discrimination policies or guidelines, like, you know, like you said, the doctor patient relationship, there is no guideline that outlines the treatment of LGBT persons. So it leaves it up to the individual doctor’s discretion to treat you, however, they want to depending on their bias.’	001, Representative of an organisation supporting LBTQ women in Singapore
Distrust towards institutions nationwide	‘.It’s the notion that if you know, you’re LGBTQ, you know, that, like, you, you shouldn’t trust any institution in this country. Yeah, and it’s like, I mean, you, you know, that you shouldn’t trust the school, you know, you shouldn’t trust the healthcare system, you know, you shouldn’t trust the like, You’re, like, wherever you’re seeking employment, whatever. So it’s like, you have to not trust by default. And if you trust by default, you will get hurt. That is just like almost a certainty, I feel.’	010, Representative of a LGBTQ university student organisation in Singapore
Cisnormativity and heteronormativity in Singapore at large	‘Yeah, I think like, whether it’s healthcare or like society, in general, there’s a very big, like, gap in, like the awareness towards queer people and queer issues. So like, with that ignorance, like people don’t address like trans people with the proper terms, or like, there is, like, there is heteronormativity, right. So like people, like, just assume that queer people don’t exist, or like queer relationships, queer love doesn’t exist’	013, Representative from a community group that shares stories of LGBTQI+ youth in Singapore
Internalised stigma as a result of national laws in place	Okay, let’s let’s talk about our clients. Like, honestly, for them to seek help is incredibly difficult, because 90% of our clients are gay men, who are using drugs and engaging in sex when they are using. Half of them are already HIV positive. So that’s three different laws that they are breaking, like the 377A thing by having gay sex, half of them are HIV positive, they don’t always consistently disclose their status to others before they have sex, and thirdly they are using drugs, right. So there’s three laws that they’re breaking. So when they seek help there’s a lot of shame, guilt and fear of like, persecution, legal implications.	006, Representative of an organisation that supports trauma survivors
Care providers not being publicly LGBTQ±affirming for fear of persecution	‘About how the transgender community accesses health care, a lot of time it’s through recommendations .a lot of word of mouth … A lot of hospitals, a lot of doctors don’t want to openly advertise that they do work with transgender clients … Even doctors then are afraid of being stigmatized by the hospital. … (We have heard of a) doctor who almost lost their license because a parent or somebody complained to the hospital, and the hospital then came down quite hard on the doctor. So again, this doctor is like, currently practicing still, but very underground.’	007, Representative of an organisation supporting the transgender community in Singapore

Table 4. Sub-theme 2: Healthcare settings compound background stigma in Singapore.

Subtheme	Quote	Interview reference number
Uncertainty about doctor’s attitudes towards LGBTQI+ issues as a barrier to thorough healthcare	‘Sometimes the question would be like, are you sexually active? … Do you mean sexually, penetrative sex? … You don’t know if the gynae meant sex with men or whether the gynae would discriminate. So a lot of them, they do not disclose their, who do not disclose their identity, do not – cannot - give their doctors a comprehensive view of their life, which impacts the care that they receive.’	001, Representative of an organisation supporting LBTQ women in Singapore
Provider’s and patient’s religious beliefs as a basis for discrimination	‘We had a client, one of the counsellors from [redacted], her client said, you know, she went in to consult this doctor on some issue, let slip that she’s lesbian, and for the first time in her life she got a two-hour lecture from a doctor about how, as a lesbian and as a Christian she shouldn’t be doing this … ’	002, Representative from an organisation supporting the general LGBTQI+ community in Singapore
Providers disregarding the validity of gender-affirming/transgender-specific care	‘There are those on the extreme end of the spectrum, where they do not know anything about the trans community, they have their certain personal beliefs against the community. And they basically don’t view gender dysphoria or the trans community … they don’t view (it) as a medical need to see us.’	008, Representative of an organisation supporting transgender individuals in Singapore
Gendered nature of healthcare administration resulting in discomfort for gender-diverse patients	‘If the medical things sort is like gender specific, and because like legally like, like, most people are recognized by the sex assigned at birth, right. So it could invoke, like a sense of dysphoria, having to like be referred to by the dead name, or like, be referred to, like, the gender pronouns, or like gender terms that do not align with their gender identity. These can be very, like dysphoric, and traumatizing experiences for trans folks try to seek medical attention	013, Representative from a community group that shares stories of LGBTQI+ youth in Singapore
Lack of research and guidelines for hormone replacement therapy for transgender individuals	‘(regarding hormone replacement therapy:) The lack of studies done by medical professionals as well, on us, because from what I understand that there just isn’t enough studies done on trans people, you know. For example, when we undergo HRT, you know, does that, because that stops our reproductive reproductive system from functioning, is there a direct relation to to cancer?… when we ask doctors, the doctors, the medical professionals, they, they themselves do not know.’	008, Representative of an organisation supporting transgender individuals in Singapore

Table 5. Multivariable linear regression models.

Variables	Attitudes		Preparedness		Comfort		Importance
	Coeff^1	95% CI^2	Coeff	95% CI	Coeff	95% CI	Coeff	95% CI
Medical School B (ref= Medical School A)	−0.044	−0.124, 0.035	0.144	−0.033, 0.322	−0.187	−0.151, 0.113	−0.125*	-0.247, −0.003
Medical School C (ref= Medical School A)	−0.206**	-0.328, −0.085	0.147	−0.123, 0.417	0.044	−0.157, 0.244	0.085	−0.101, 0.371
Year of Study	−0.003	−0.049, 0.043	0.047	−0.054, 0.149	−0.290	−0.105, 0.047	−0.065	−0.135, 0.006
Female (ref = Male)	0.016	−0.057, 0.301	−0.204*	-0.366, −0.421	−0.030	−0.150, 0.090	0.176**	0.064, 0.288
Others (ref = Male)	−0.148	−0.597, 0.301	−0.733	−1.732, 0.266	−0.140	−0.882, 0.602	0.196	−0.492, 0.884
Abrahamic Religion (i.e., Christianity or Islam)	−0.108*	-0.192, −0.024	−0.118	−0.304, 0.677	−0.208**	-0.346, −0.070	−0.025	−0.153, 0.103
Knowing someone LGBTQI+	0.058	−0.051, 0.167	0.051	−0.192, 0.293	0.088	−0.092, 0.268	0.177*	0.009, 0.344
Identifies as an ally (ref= does not identify)	0.311***	0.226, 0.381	0.306**	0.115, 0.496	0.326***	0.184, 0.467	0.366***	0.234, 0.497
Identifies as LGBTQI+ themselves (ref= does not identify)	0.256***	0.131, 0.381	0.148	−0.130, 0.426	0.416***	0.209, 0.622	0.423***	0.231, 0.614

¹Coefficient.

²95% Confidence Interval.

*p < 0.05 **p < 0.01 ***p < 0.001, bold text indicated statistically significant estimates.

Table 6. Sub-theme 3: Overlapping, intersecting stigmas and consequences of stigma.

Subtheme	Quote	Interview reference number
Self-medicating at unsafe doses on hormone replacement therapy	‘We did have a client who, who did self-medication and then for that he has been overdosing on it. Yes, yeah. Because there’s this misconception that, you know, when when you inject … more testosterone, you, you have the misconception that you will transition faster, the result of coming faster … At the same time, it’s very dangerous, because you never know if there are any side effects for having so much, you know, hormones in your body.’	008, Representative of an organisation supporting the transgender community in Singapore
Biased assumptions from a healthcare provider resulting in missed diagnosis	‘… As it turned out, this person was presenting COVID symptoms. So, it was something along the – I suppose you could say it was a quick assumption this doctor had made, that you know, sexually active gay men presenting oral symptoms – must be oral STI, right? And then only ordered the oral STI tests, but not COVID.’	002, Representative from an organisation supporting the general LGBTQI+ community in Singapore
Inability to access gender-affirming care leading to adverse mental health outcomes	‘With the Ashlee case (a well-known account of a transgender youth who was disallowed from seeking gender-affirming care by her school in Singpaore), we were quite involved in that as well, in terms of … the issues she faced. She mentioned that, like, how it impacted her mental health and led to suicidality. So because of the inability to seek trans health care, the mental health issues come down.’	001, Representative of an organisation supporting LBTQ women in Singapore
HIV-related laws preventing access to care of non-Singaporean patients	‘So I have a client, because he’s a foreign student, he didn’t want anyone to know that he has HIV, because of fear that if they will know, then he cannot continue his studies anymore. Um, so he actually didn’t seek help for like, a while. … And finally, when he reappeared again, he looked really, really sick … . the moment he gets treated in Singapore ... means his student pass or student visa will be revoked.’	003, Representative from an organisation which works towards addressed sexual health in Singapore
Elderly transgender individuals feeling like outcasts and avoiding the healthcare system	But we do see a lot of cases where, you know, they come and stay in [redacted – organization being interviewed] and they have not sought, they’ve not gone to the doctor, and yes, they’re supposed to have regular follow ups, they don’t go. We have had cases where the person was having eyesight issues, cataract, and just had not gone to the doctor for like, to check on it at all … for the older trans community, they already see themselves as outcasted. … They’ve lived in a society where they they accepted the fact that they are not going to receive any help.	007, Representative from an organisation that supports the transgender community in Singapore
Language and socioeconomic class as a cause of differential access to knowledge of LGBTQ±affirming services	‘… With language and socioeconomic class,… say, the English-speaking community, and knowing that “okay, yeah, this doctor is gay-friendly one. May charge a bit more, but yeah, he’s the one to go to.” And knowing the right people, and sometimes it almost feels like that old boys’ network … whereas somebody else, who may not be plugged into that English-speaking professional class or social context, or … may just be using different social media apps, or just interacting with different groups on social media, just would not have this information.’	002, Representative from an organisation who supports the general LGBTQI+ community in Singapore
Treatment of LGBTQI+ minors being dependent on parent’s preferences for care	‘I think it’s, there’s an additional layer of complexity when it comes to youth, especially the legal minors. So because the parents ultimately have control over the health care of the kids … what kind of medical help they can seek, especially if we’re talking, if we’re talking about mental health issues. It really heavily depends on what the parent wants for the kid.’	005, Representative from an LGBTQI+ brand serving the LGBTQI+ community

Table 7. Sub-theme 5: Recommendations to reduce stigma in healthcare and beyond.

Subtheme	Quote	Interview reference number
Recommendations regarding general socio-legal environment in Singapore	‘I think a lot of it has to come from: what kind of examples are you setting? … How is it institutionalised? So obviously, official policies need to be changed, that’s the most straightforward and impactful way you can improve stigma. If [national media regulation authority] decides that they won’t hate gay people or queer people anymore, then it will make a huge difference in terms of media representation, in terms of the discussions, in terms of people just being able to see themselves on the TV … for young people who are growing up, it makes a huge difference to the future mental like, well being.’	005, Representative from an LGBTQI+ brand serving the LGBTQI+ community
Recommendations regarding healthcare-specific policy	‘One thing that I do in terms of my work at [redacted – restructured hospital centre where interviewee works] is: We have to come up with guidelines … when we talk about pap smears, we would say that a pap smear is applicable to people with vaginas, instead of saying that all females should do a pap smear, because that can be quite transphobic.’ ‘There are still community mental health providers. But that’s very few … it would be good if our government hospitals and all that can actually set out these safe spaces.’’	009, Representative from an organisation supporting the general LGBTQI+ community in Singapore 003, Representative from an organisation which addresses sexual health in Singapore
Suggestions for content in medical education	‘I think [for] a lot of healthcare professionals, training comes from folks who don’t actually know the community. So I think it’s more like working with a community to get them to provide that kind of training’ ‘Having basic gender sensitivity … understanding how to be a supportive ally … learning to be patient with your patient … using the right name, using the right pronouns … just [a] general level of sensitivity. The basics [are] important.’	012, Representative from a community group advocating for the bisexual population in Singapore 007, Representative from an organisation supporting the transgender community in Singapore
Suggestions for delivering LGBTQI+ related health content in medical education subtly	‘I don’t know if introducing a LGBT health-specific module in medical school is going to help … that might be putting a square peg in a round hole, because it may not be fitting what we need. I wonder if a more … “sneaky” way might be helpful. I mean, talking about communication skills, start there–…using more nuanced language … more open, gender-neutral language … not jumping into. assuming, before your patient tells you what their needs are.’	002, Representative from an organisation supporting the general LGBTQI+ community in Singapore