A Stakeholder Analysis of the Current Lebanese Context for Transgender Healthcare: The Perspectives of Non-Governmental Organizations
Kate Wright, Brandon Peplinski, MPH, Sarah Abboud, PhD, and Omar Harfouch, MD, MPH
Lebanese Medical Association for Sexual Health
Johns Hopkins Bloomberg School of Public Health
Executive Summary
Currently there is little knowledge on the state of transgender health in Lebanon. In this stakeholder analysis, four non-governmental organizations (NGOs) representatives that work with the transgender population were interviewed to better understand the Lebanese context for transgender healthcare. NGOs emphasized that discrimination and abuse are highly prevalent towards transgender people, including persecution by law enforcement, which often limits education, employment, and housing. Access to healthcare is limited by a lack of insurance for transgender services, discrimination by healthcare providers, insufficient knowledge among providers to appropriately communicate with and treat these individuals, and a general lack of competent providers for transgender needs. NGOs agreed that advancing provider education on transgender health issues is vital for improving the health of the transgender population. Although transgender individuals have access to some medical care, legal aid, psychological support, and community support through local NGOs, health services are not comprehensive, and there is generally little awareness in the community regarding the available services and support. This analysis emphasizes the need for next steps in education and training, awareness and communication, and advocacy. Information on current available resources should be better disseminated to the transgender population and health professionals.
A robust transgender health curricula should be implemented in the healthcare provider training process, and trans-friendly providers and NGOs should emphasize networking and collaboration. Communication campaigns may help shift societal perceptions on transgender persons. Further research should be done to direct advocacy, communication, and health program work. Our findings were consistent with previous research on discrimination towards transgender people in Lebanon, and future work should examine these questions from the perspective of transgender people to better elucidate their needs and input.
Introduction
Transgender individuals experience stigma and discrimination globally with few sanctities of safety.1 Although Lebanon does not legally condemn transgender identities—indeed the country can provide protection from arrest with a diagnosis of gender dysphoria2—the current situation does not invoke ease for transgender individuals living there. Family and societal rejection permeates the culture with abuse and discrimination common occurrences.3, 4 A vast majority of the general population considers dressing like the opposite gender as perverted and changing gender identities through surgical procedures as immoral.5 Discriminatory treatment of transgender people can lead to reduced opportunity for education and employment opportunities,3, 4 as well as increased risk for negative mental and physical health outcomes, including depression, suicidal behaviors, and HIV/AIDS.3, 4, 6
Regardless of the legal landscape, transgender individuals continue to suffer at the hands of Lebanese law enforcement through arrest and torture, using Article 534 of the Lebanese Penal Code among morality laws as justification.5, 7, 8 Additionally, an individual is compelled to undergo sexual reassignment procedures in order to change identification papers, solidifying the binary gender requirement and ostracizing those who are gender nonconforming.5, 9, 10 That being said, a transgender identity is typically considered a medical or psychological concern, resulting in some sympathy for transgender individuals from society. Many people believe that they need help rather than punishment and do not condone the use of violence or abuse against them.5
Legal progress has been made in more recent years with a seeming shift in perspective, although severe abuses against transgender people continue to occur. In September of 2015, the Court of Appeals of Beirut ruled in favor of a transgender man regarding his fundamental right to legally change his gender marker to male, including his right to treatment and privacy.11, 12 Contrary to this development, in 2013, a transgender woman and two homosexual men were arrested and verbally and sexually abused. The transgender woman was stripped naked and photographs were taken of her and subsequently distributed to the media.8, 13 Progress is certainly occurring, but there is still work to be done.
To date, there is little knowledge surrounding transgender health in Lebanon and basically no understanding of provision or coverage of transgender-specific services. In this stakeholder analysis project, local non-governmental organizations (NGOs) that work with the transgender population were interviewed to better understand their perspectives on the current context for transgender healthcare in Lebanon
Methods
A stakeholder analysis of the current context for transgender healthcare in Lebanon was performed, targeting NGOs working in transgender health. Stakeholders were recruited using purposive sampling and were contacted based on the sample of NGOs that focus on transgender issues in Lebanon.
A Lebanon-based employee of the Lebanese Medical Association for Sexual Health (LebMASH) conducted the NGO representative interviews. Interview questions were open-ended and included the following topics: NGO provision of services; community response to services; community perceptions of transgender individuals; availability and cost of healthcare providers and services specific to transgender healthcare; access to health insurance; obstacles to obtaining healthcare; and recommendations for improving provider education. All stakeholders gave informed verbal consent to be interviewed and quoted anonymously. De-identified interview responses were compiled for each interviewee, and a summarization was performed, including major themes, agreements, and disagreements in the responses.
Results
Four NGO representatives in Lebanon responded to the inquiry. Each organization provides different services to the transgender community, including advocacy, psychosocial health, medical care, social and legal services, and knowledge production. Table 1 provides a summary of these services. The interviews resulted in a number of themes related to the current situation for the transgender population in Lebanon that we present in the following sections.
Discrimination and Stigma
| “The ‘masculine’ gay men regard trans women as having a bad reputation on the gay community because of them. The community does not stand together unfortunately.” |
| “We’ve seen people who have been kicked out of their houses, didn’t attend school or college, were forced to live in the streets…they had to do sex work.” |
All four NGO representatives emphasized discrimination and stigma as a prevalent and persistent reality for the transgender population. Throughout the interviews, they listed a number of different groups—including law enforcement, healthcare providers, community members, and family—who subject transgender people to physical and emotional abuse, rejection, and marginalization in response to their gender identity. All NGO representatives addressed the problem of job scarcity for transgender people because of their gender identity, resulting in many of them turning to survival sex work, putting them in danger of arrest and sexual assault from law enforcement. At points, the discussions turned to the general lack of information about transgender people within Lebanese communities, and all four representatives agreed that family rejection in particular is common. One representative brought up the concern that even the LGB community discriminates against the transgender population specifically. This pervasive culture of discrimination contributes to the mental health risk that transgender people experience, as noted by all four NGO representatives.
Medical Atmosphere
| “When it comes to hormonal therapy, we only have one doctor we refer to. There was another person we tried to engage with, and he refused. There is resistance among healthcare providers.” |
In addition to Lebanese society’s norms and perceptions of the LGBT community, the medical atmosphere presents difficulties for the transgender population. All NGO representatives concurred that insurance companies across the board do not cover transgender-specific health services, so any treatment must be paid for out-of-pocket. Because many transgender people struggle to find employment, paying for healthcare is often impossible. According to all representatives interviewed, this population struggles severely with access to care in general. Some healthcare providers turn transgender individuals away, refusing to treat them. One representative noted that many transgender people avoid accessing care due to a fear of breach of confidentiality, rejection, or humiliation. As a result, many transgender people do not seek or receive medical care at all.
| “This is a big risk for transgender persons because they will start hormone therapies for themselves, there will be complications, they will have to stop it, they start to have the features of the opposite sex, then they go back to zero.” |
In addition, most healthcare providers lack the knowledge necessary to appropriately communicate with and treat these individuals in a way that is suitable to their specific needs. One representative noted: “There are people who might be willing, but they are not experienced so this is another challenge.” There is also a lack of providers available for specific transgender needs, such as speech/voice therapy, hormonal therapy, gender-affirming surgery, and mental health services catered to the transgender experience. Three representatives discussed the difficulties and dangers transgender people face regarding hormonal medication due to a lack of knowledge regarding the process
for safe hormone use alongside the likelihood of inconsistent financial means.
Gender Dysphoria
| “If I get arrested by the police…I give them the ID and I give them the report for gender dysphoria, they back off because a doctor said they have a medical condition and here in Lebanon we regard doctors very highly.” |
Two out of the four NGO representatives addressed the psychiatric diagnosis of gender dysphoria and its effect within the transgender community in Lebanon. In some ways, this diagnosis aids them. Although it does not protect against societal or family rejection, it does provide protection from arrest because Lebanese law recognizes the condition as a mental health concern. Avoiding legal discrimination offers invaluable security, physically and mentally, to this population. A diagnosis of gender dysphoria is also the first step to changing identification documents, a process that is lengthy but not impossible in Lebanon. Even Islam accepts gender dysphoria as a medical condition, according to one key informant.
| “When someone doesn’t know about something they’ll keep fearing it, they’ll keep not knowing how to deal with it.” |
Improving provider education. All four NGO representatives agreed that advancing provider education in Lebanon is vital for improving the health of the transgender population and for reducing stigma within the medical community. A variety of recommendations arose for promoting education. Two representatives mentioned the importance of including transgender health as part of the curriculum for health professional students. One representative felt that both students and professionals should receive three levels of curricular education. First, a focus on respect presents a base for future knowledge: “I think the education under the respect of a human being, their freedom, that their right to be themselves in their body, in their appearance, etcetera, so when you understand this, I think automatically your behavior and your services will follow.” Second, curricula should include details about healthcare needs and risks specific to the transgender population. Finally, a focus on the role that society plays, particularly regarding mental health, can encourage understanding and promote a shift away from discrimination within this section of the community in Lebanon. This representative also mentioned the significance of health care providers accepting a transgender identity as normal, especially as an effort to advance mental wellness, because the questionn—“Am I normal?”—arises often with transgender individuals.
Another representative had three main recommendations for improving provider education. First, keeping providers involved in the learning process will offer a welcoming and appropriate setting for education. Asking them what they already know about the needs of the transgender population as well as how transgender individuals are currently treated in their practice can encourage reflection within the providers. By starting with what they already know, educators can shift their knowledge base towards what they need to know for proper and just treatment. Second, this representative recommended starting broad and then moving to specifics to encourage a more open and welcoming attitude from the providers. Finally, a strong emphasis was placed on the importance of a thoughtful approach in an effort to avoid turning people away or creating an uncomfortable situation.
| “If I’m a health care provider…and I get a patient, it’s my duty—it’s my sworn duty—to treat them well; to communicate with them well and provide accurate treatment with them and diagnose them well. If I don’t want to do this thing, I should refer them to somebody else who will do it.” |
Focusing on improving health care settings and emphasizing comprehensive care brings providers into an educational mindset. Including concepts of provider success can also be helpful, such as the potential for increasing client base or renown within the community. Workshops and trainings were also suggested as a means to educate healthcare providers. Two representatives discussed the importance of avoiding discussions or lectures surrounding what is right and wrong, and instead emphasizing the importance of medical care. Finally, one stakeholder strongly emphasized the idea that even before education, the first step towards improving treatment of transgender individuals is to hold healthcare providers accountable and to make them responsible for their actions.
Discussion
Several themes emerged throughout this analysis. Most common was the assertion that transgender individuals in Lebanon experience stigma and discrimination in all parts of life. Rejection is common from both families and society at large, as is verbal, physical, and sexual abuse. Secondary to such discrimination come difficulties in obtaining education, employment, and housing, which can lead to poverty, survival sex work, and mental health co-morbidities. For transgender people, there is a significant risk to seeking healthcare, “coming out” to family or the community, and even simply to be oneself.
The success of the recent decision regarding a transgender man’s right to change his identity can be considered a starting point for positive change in Lebanon. Legal avenues can be used to promote transgender rights and acceptance within society, especially alongside the “protective diagnosis” of gender dysphoria. That being said, none of the representatives interviewed discussed how this diagnosis impacts the mental health of transgender individuals or the treatment provided by medical care providers, specifically mental health providers; more information regarding any underlying impact is necessary.
Within the healthcare system, a dearth of knowledge exists regarding transgender people and transgender health, and when combined with pervasive discrimination, negative attitudes and unethical practices abound. Transgender people accordingly often avoid seeking healthcare in order to protect themselves from the potential abuse that occurs within the system. The NGO representatives cited a common problem of identifying providers who are competent, respectful, and available to meet transgender-specific health needs. This lack of information applies to the availability of and access to several other aspects of transgender health, such as hormone therapy, health insurance coverage, or support groups. Broadly, few identified competent and non-discriminating providers exist, and there is little knowledge in the community about access to services and support—an important consideration in light of other economic and social obstacles that transgender people face in accessing care. This shortage of connectivity and information presents an opportunity for education and outreach to care providers, NGOs, and the transgender population to increase awareness of what is available and to create an integrated network of services.
Transgender individuals in Lebanon, specifically in Beirut, do have access to some medical care, legal aid, psychological support, and community support through local NGOs, however these services are not comprehensive. Services provided through specific NGOs are highlighted in Table 2.
There were several limitations to this project. First, the number of NGO representatives interviewed limited the comprehensiveness of perspectives and experiences that could be achieved. We are not able to characterize how prevalent negative attitudes or discriminatory practices are in the healthcare system, or what percentage of transgender people experience rejection by family and friends. Nevertheless, a significant level of agreement and many common themes emerged throughout the analysis, which may represent sampling saturation and indicate adequate numbers for the purpose of this project. Additionally, because the number of NGOs in Lebanon that have experience working with the transgender population is very small, our sample sizes may represent eligible stakeholders in the Beirut area. Our project findings are also consistent with previous work that performed a more thorough and quantified evaluation of negative public attitudes and discrimination towards transgender people in Lebanon and elsewhere.5, 14 This project was limited to Beirut and did not represent the perspectives of target groups outside this area; however it is commonly perceived that the majority of the transgender population, and subsequently the relevant stakeholders, live in Beirut.
Further studies may investigate differences in the context for transgender healthcare in rural areas compared to Beirut. Finally, because of IRB issues and difficulty reaching the transgender population, this project does not capture the most important stakeholder group—the transgender population itself. Future work should be done to examine these questions from the perspectives of transgender people in a way that elucidates their needs and input.
Recommendations and Conclusion
This analysis may lead to several appropriate next steps in the areas of education and training, awareness and communication, and advocacy through social, legal, and healthcare avenues. All recommendations emphasize basic principles of respect for transgender persons. Recommendations include:
- Dissemination of information on current available resources to the transgender population and to health professionals at all levels of training
- Resources around competent and culturally sensitive locations and providers for primary care, mental health care, hormone therapy, sexual health, surgical care, support groups, and other transgender-related services. LebMASH’s LebGuide is a growing directory of LGBT affirming providers who could help with this information.
- Development and implementation of transgender health curricula early in the educational and training process; examples of effective curricula that can be adapted to fit the Lebanese context include:
- Optional and recurrent transgender-specific sessions at health profession schools15
- Combined interactive e-learning modules with an in-person, observation experience in a relevant location16
- Case studies to address transgender-specific concerns alongside defining terms and identifying personal bias in an online, in-person, or hybrid format17
- Online self-study module utilizing readings and videos along with self-assessment and case-based learning activities18
- Networking and collaboration between providers, trained and knowledgeable in transgender health, and transgender-friendly NGOs and sexual health centers
- Coordinate work in transgender health
- Easily disseminate information to the transgender population
- Easy referral to available services and resources
- Provide quality and culturally sensitive integrated transgender-specific health services
- Communication campaign in conjunction with NGOs and healthcare provider stakeholders to shift societal perceptions on transgender persons
- Focus on educating and supporting parents and families of transgender individuals
- Further research to direct future advocacy, communication, and health program work
- Input from the transgender population
- Input from healthcare providers
We hope this analysis will help all stakeholders for transgender health in Lebanon understand the current context, raise awareness and communication, and coordinate efforts to meet the needs of the transgender population. In the future, stakeholders should work together to improve the current context in a way that fosters a healthy environment for transgender individuals while also meeting the immediate sociocultural and healthcare system context in Lebanon.
Table 1. NGO Services Provided to the Transgender Community
| Psychosocial | – Psychotherapy, counseling– Psychosocial health (drama therapy, group support, life skills)– Psychological follow-up through transition– Psycho-education for family members |
| Medical | – Free medical care– Free, rapid STI testing– Hormonal therapy– Referrals to transgender-friendly healthcare providers (psychiatrists, surgeons, endocrinologists, primary care) |
| Legal | – Advocacy– Lobbying– Legal support (help with arrests, work on papers) |
| Social | – Support groups– Connection to other transgender individuals through personal networks |
| Education | – Knowledge production (needs assessments, manuals, advocacy plans, capacity building) to help local NGOs better serve the transgender population– Training for other NGOs to understand transgender people and needs– Training for healthcare providers to improve knowledge and understanding of transgender people and needs |
Table 2. Local transgender-friendly NGOs
| NGO | Provision of services |
| The Legal Agenda | Advocacy group working to impact and alter laws in Lebanon to reduce monopoly of power and improve social justice, including transgender rights19 |
| Helem | – Sexual health center.– Low or zero-cost education and social support– Advocacy for transgender rights locally and internationally, especially through policy and local awareness– Works within the LGBT population to reduce HIV/AIDS and other STIs 20 |
| Marsa | – Sexual health center.– Free medical care, including mental health and primary care, rapid STI testing, sexual health services, hormonal therapy, and psychotherapy 21 |
| MOSAIC | – Psychotherapy, including throughout transition for individuals who choose to transition– Support group for transgender people; education for family members to encourage acceptance and understanding22 |
| The Restart Center | – Psychosocial, medical, and physical rehabilitation to survivors of violence and torture23 |
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