VCR Diary, Commentary, Jun '19
Sadam Hanjabam on the unaddressed mental health needs of queer youth in Manipur
Manipur has a huge hidden queer population, which has existed amid socio-political conflicts, resistance movements and heavy militarization since a long time. The state is plagued with high rates of school drop-outs and unemployment among youth. Adding to the complexity, Manipur has one of the highest HIV prevalence rates in India. According to the National AIDS Control Organisation, Manipur has an adult prevalence rate of 1.43 percent, which is the second highest in India (2017 data). The state shares 398 km of an international border with Myanmar, which is part of the infamous Golden Triangle. Manipur’s proximity to the Golden Triangle leads to easy and cheap access to all forms of drugs. Many of the youth in the state engage in substance abuse in one form or the other.
What does such a scenario imply for the mental health of youth in Manipur, and in particular queer youth? Not enough has been done to address the issues and struggles of queer people in the state. Perhaps this is because the invisibility of ‘out’ queer people has long been interpreted as their non-existence.
While the privileged youth manage to migrate to other states of India for education or employment, a much larger number of youth with no significant qualifications or jobs remain within a stressful environment and become prone to mental health concerns, including suicidal tendencies. For queer youth, migration has added significance – it becomes a way of exploring their identity and living a ‘liberated’ life beyond the state, free from judgmental attitudes. But those who are not in a position to migrate have to contend with daily struggles of lack of opportunities, whether it is in the context of education, employment or self-expression!
How prepared is Manipur to deal with mental health concerns of queer youth?
Not much at all according to Mala Lisham, who works on child rights with the Department of Social Welfare, Government of Manipur. She says, “Stigma and discrimination are the main causes that prevent LGBTI youth from coming out and discussing their sexual orientation, gender identity and gender expression. This in turn leads to a risk of depression, stress disorder, self-destructive behaviours, and even suicidal tendencies.” What is missing therefore is a youth-friendly and queer-affirming support system.
Mental health practitioners Dr. Ketki Ranade and Shruti Chakravorty have observed in Gay-Affirmative Counselling Practice – Resource and Training Manual (a publication of the Tata Institute of Social Sciences, Mumbai, 2013) that most of the mental health clinics and professionals across India have hetero-normative assumptions (this would be true of Manipur as well). The clinic set-ups are not queer- friendly and ignorant of the concerns of queer people. The attitude and language used by the professionals is often queerphobic, which is likely to have a negative effect on their queer clients.
There is limited scholarship on queer issues in Manipur, particularly on mental health concerns. But according to a study conducted by G. S. Soohinda, P. S. Jaggi, H. Sampath and S. Dutta titled Depression and Its Correlates in Men Who Have Sex with Men in India (published in the Indian Journal of Social Psychiatry, 2018), depression was present in 163 (59 percent) of the total 277 respondents to the study.
K. Sathish Kumar and Brogen Singh Akoijam in a study titled Depression, Anxiety and Stress among Higher Secondary School Students in Imphal, Manipur (published in the Indian Journal of Community Medicine in 2017) found that the prevalence of depression, anxiety and stress disorder among the respondents was 20 percent, 24 percent and 21 percent, respectively. Overall, 82 percent of the total 830 respondents had at least one of the three mental health problems mentioned, and 35 percent had all three negative states of mind. It would have been pertinent to find out to what extent the prevalence of these mental health problems was linked to stigma and discrimination around gender and sexuality difference. Apart from international bodies like the World Health Organization, even the Indian Psychiatric Society (IPS) no longer considers homosexuality or gender variance to be a disorder or disease. The Manipur state branch of the IPS has been proactive in organizing awareness generation events on the mental health concerns of queer people in collaboration with NGOs like SAATHII. In spite of these developments a change in thinking does not seem to have taken place among many healthcare providers in Manipur. The idea that queer people can be manipulated and cured through medication and therapy still prevails.
Unlike urban centres in other parts of India, which have numerous options in terms of private clinics, hospitals and health networks, Imphal or other cities in Manipur do not have even one designated healthcare institution to address mental health problems. All counselling centres in the state are attached to general hospitals run by the government. Beyond the capital Imphal, the interior and rural areas of Manipur have even poorer access to mental health services.
Consider this statistic to get an idea of the dismal state of affairs – the National Mental Health Survey of India, 2015-16 conducted by the National Institute of Mental Health and Neurosciences showed that there were only 16 psychiatrists and 14 clinical psychologists for the entire population of Manipur. That worked out to less than one psychiatrist or clinical psychologist for every 100,000 people!
Within this environment of poor availability of mental health services, Paonam Thoibi, an Imphal-based psychotherapist, talks about another dimension to the problem. She emphasizes concerns around pathologizing mental health concerns of queer people and addressing them without a deeper understanding of the underlying causes: “Many people don’t know the role of counsellors or therapists; they go directly to psychiatrists. Unfortunately, many psychiatrists do little to help queer youth open up about the root cause of their problems and instead prescribe anti-depressants or other forms of medicines. This often creates a treatment gap.”
How likely is it in such a scenario for a queer individual in Manipur to find mental health support from a professional, especially one who is queer-friendly?
Deeper into the problem, nuances beyond numbers
Policymakers often tend to ignore the concerns of adolescents and older youth (including queer youth). Youth policies are generally framed without consulting who they are meant for. The lived experiences of young people are overlooked, and when it comes to sex, gender and sexuality, everything is seen from the perspective of heterosexuality, gender binary and monogamy.
In addition, queer issues are not only dismissed as an urban phenomenon, but the diversity within the queer communities is also not recognized. The different identity, demographic and socio-cultural contexts of queer people do not register with the policymakers. This often reflects in the under-representation of different queer communities in sexual, reproductive and mental health programmes run by the government or even civil society organizations. This in turn raises the concern of equitable access to health and related services for all queer people.
For instance, while Manipur has seen several government-funded HIV interventions for some sections of men who have sex with men (MSM) and trans women, other queer communities have been left out of these programmes. A young gay man, a student, who wants to remain anonymous says, “We feel uncomfortable going to health clinics that are not queer friendly”. He adds: “Even the HIV targeted interventions run by MACS have mostly trans women as employees, even though they say that the interventions are also for MSM. Since the issues of MSM and trans women around HIV may be different, we feel the lack of an HIV intervention run by the government that acknowledges the diversity of queer communities and their different concerns around HIV and other health issues.”
Besides, most HIV interventions in Manipur are focussed narrowly on medical aspects of HIV prevention and treatment, completely ignoring the cyclical link between mental health and HIV vulnerabilities. No wonder then the high levels of HIV prevalence in the state.
Further looking into the context of mental health, different queer communities in Manipur may experience different types of mental health problems. But most mental health professionals have not recognized this aspect, leave alone government bodies in the state that are yet to grapple with the issue of mental health for queer people itself. Thus perhaps the most under-served and neglected sections of queer communities in Manipur in terms of any kind of health programme are the lesbians, bisexual people, trans men and young people across all these queer sections.
A young queer woman from Imphal says, “Young bisexual men and women and lesbians need special attention for health services, including sexual and reproductive health and mental health services. These are serious gaps that need to be addressed urgently.”
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There cannot be any quick fixes. But fortunately we now have a legal and policy framework that can help overcome barriers to talking about queer people’s health, well-being and civil rights. Section 377 of the Indian Penal Code has been read down by the Honourable Supreme Court of India to decriminalize queer people. The Mental Healthcare Act, 2017 prohibits discrimination in any sphere of mental health service provision on grounds of gender identity and sexual orientation.
Capitalizing on these developments, one of the urgent needs is to start early, that is, to initiate comprehensive gender and sexuality education in schools and colleges, and stop peer victimization, bullying and isolation faced by queer students. This is likely to have a beneficial impact on the mental health status of queer students, prevent drop-outs and bring down the chances of their practicing self-harming behaviours like unsafe sex, substance abuse or using violence to settle matters.
Regional support systems and networks involving queer communities, mental health and other healthcare providers, government officials and even the media must be created to grasp the entire scale of the problem and plan remedies. Such systems need to be grounded in Manipur’s socio-cultural realities.
If queer lives matter, if young people’s lives matter, then the time to act is now. We need to prioritize the mental health needs of queer youth in Manipur, or the state will continue to lose its young generations – through migration, loss of health, and – no doubt about it – also through loss of life!
About the main photograph: Regional Institute of Medical Sciences (RIMS), Imphal is a key government hospital and medical college in Manipur – the psychiatry department in the RIMS is one of the few clinics in the state that is considered to be queer-friendly. Photo credit: Bonita Pebam