Where homosexuality is a crime, gay health workers face tough choices

Being gay and working in global health presents a unique set of issues, as many countries treat homosexuality as a crime, punishable by prison or death.

- By Ruthann Richter

Jason Nagata

Jason Nagata, MD, sat in a wooden pew in a Seventh Day Adventist church in Kenya, listening to the pastor thunder away about the “abomination” of homosexuality. Nagata, then a medical student, began to sweat profusely, his face dripping and his palms wet. Flanking him in the church pew were members of his Kenyan host family, who had no idea he was gay.

“It was clear all the people in the church had similar viewpoints, as they were nodding in agreement with the pastor,” he said. “I think I was just trying as hard as I could not to let anything show on my face.”

In a recently published commentary, Nagata writes about the challenges of being gay and doing global health work in countries where homosexuality is a crime, punishable by death or imprisonment, and where those legal constraints are often mirrored in societal attitudes. The commentary, written while he was a pediatric resident at Stanford, was published online Jan. 6 in Global Health Promotion.

Nagata said the challenges became painfully apparent when he went to Kenya in 2010 to do research on nutritional support and food insecurity among HIV-positive individuals there. He was based in Mfangano Island, a rural fishing and agricultural community in Lake Victoria, where HIV prevalence is high among the highly mobile population.

At the time, the Kenyan government was considering a constitutional amendment to provide protections for LGBT individuals, who under Kenyan law may be punished with up to 14 years in prison. The proposed amendment was the subject of much heated public debate and was fiercely opposed by the pastor at the church that Nagata and his host family attended, he said.    

‘A challenge I have grappled with a lot’

A few years earlier, Nagata had told his parents, both ordained clergy, that he was gay, and they had been supportive, he said. But he could not imagine how his host family or his Kenyan colleagues might react to this news, given the very different political climate for the LGBT community in the East African country.

“It’s a challenge I have grappled with a lot,” said Nagata, 30, who is now a fellow in adolescent medicine at UC-San Francisco. “I wondered to what extent it would be safe or practical to come out to colleagues whom I would be working with internationally. Because coming out is a very big deal. I was still hiding a big part of myself from others, like my host family.”

Michele Barry, MD, professor of medicine and director of Stanford’s Center for Innovation in Global Health, said she advises medical residents working abroad to be cautious on issues of sexual identity. The center sponsors the Johnson & Johnson Global Health Scholars program, which sends residents abroad for rotations of up to six weeks.

“I talk to the residents about really being very circumspect and suggesting that they not share their sexual orientation,” she said. “I think it can be very charged information. I give residents an opportunity to opt out of the program if they don’t feel comfortable in not being open about their sexuality.”

Value vs. risk of openness

Barry said she views the issue in the context of respecting local culture.

“It’s like dressing culturally appropriately, even if you don’t agree with it. It’s very akin to women who go into a culture where they have to wear a hijab,” she said. “They may not agree with it, but they are guests in the country, so I ask them to respect that others wear a hijab and not argue the fact. We have to be respectful of the culture.”

In his commentary, Nagata weighs the value of being open about one’s sexual minority status with the possible risks and dangers of exposure. He said U.S. clinician-scientists may change minds and open up the conversation on the issues by revealing their status to people who might not otherwise interact with an LGBT individual.

I was still hiding a big part of myself from others, like my host family.

“People’s opinions of LGBT rights and same-sex marriage might be changed if they experience solidarity with an LGBT family member or friend,” he wrote.

U.S. scientists also may have the opportunity to advocate for change in their host countries by working with local activists who are experienced and understand the risks, he said. For instance, they could seize the opportunity to call attention to the health issues prevalent in the LGBT community and the difficulties these individuals face in finding doctors willing to treat them and able to provide appropriate care. Because of stigma and discrimination, LGBT individuals are more prone to anxiety, depression and suicide and suffer from higher rates of HIV and sexually transmitted diseases, he said.

He said researchers from the United States who are open and speak out on the issues might be somewhat insulated from backlash because they come from a country where LGBT rights are protected.

On the other hand, he said, they have to be cognizant of the risks they may face, including physical violence. “Not everyone can be a martyr and put their lives in danger for a cause,” he writes.

‘It’s a conundrum’

Barry agreed. “I completely empathize with the urge to show solidarity, but it’s not the time to endanger yourself,” she said. “It’s a conundrum.”

In his own case, Nagata said he agonized about how to approach his Kenyan host family, whom he plans to revisit to continue his work.

“Even as some of my friends and colleagues reviewed the article, they advised me not to come out under any circumstances to my host family,” he said. “Though sentiments have changed in the United States in recent years, there are still very strong sentiments [against homosexuality] in Kenya. So while I think it would be an interesting viewpoint for them to hear, I could see them saying, ‘You’re not welcome anymore.’”

For the moment, he has decided to confine his advocacy to working from afar by writing about the issues.

“I think my advice overall is that there is no one right answer for how to deal with this,” he said. “People have to balance the potential risk of adverse consequences with their own ideals for advocacy and promotion of universal human rights.

“While it would be great to fight for a cause you believe in, there are also practical consequences to think about,” he said.    

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu.

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