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  • Josephine Chinele—Malawi

Improving LGBTQ+ care among Malawi’s health workers

In Malawi, pervasive stigma and discriminatory attitudes among healthcare workers hinder access to healthcare for the LGBTQ+ community. A pan-African community-minded philosophy is helping to build bridges. 

In Malawi, stigma among healthcare workers limits LGBTQ+ healthcare access. A community-minded philosophy is helping to build bridges. Photo: Anete Lusina

After being denied treatment at a public health facility in Lilongwe, Malawi, a transgender woman resorted to using salt and water on anal wart sores. She had no money to buy medication or consult a private clinic, and nurses at the public health facility had refused to treat her upon learning she had HPV, the STI that caused the sores. The salt and water remedy did not help and the disease worsened, until a colleague took her to another public hospital. She stayed there for three weeks.

In her village, rumours were rife that she was dead. After her discharge, people “mocked her that she was a ghost, that she has escaped from the grave and God has given her a chance to repent if she does not want to go to hell,” reads a 2021 Civil Society Report on LGBTQ+ rights submitted to the Human Rights Committee. The report highlighted several incidents of health workers’ poor treatment of LGBTQ+ people in Malawi.

The villagers even accused the woman of killing a neighbour’s child, who died on the same day she returned. Then they burnt her house “to chase her out from the village”.

This is not an isolated case in Malawi. Zoa*, a 42-year-old LGBTQ+ peer educator who lives in Mulanje, says it has always been difficult for health workers to support members of the LGBTQ+ community when they have conditions related to sexual health. “When it’s malaria or other issues, it’s not a problem,” he says.

In Malawi, homosexual relationships are an offence punishable by a maximum of 14 years’ imprisonment. As such, Zoa, who knows over 200 LGBTQ+ people in his local area and is himself a member of the LGBTQ+ community, says most of them conceal their sexuality.

“The society regards [LGBTQ+] as an alien thing. To them, a relationship is only that of a man and woman,” he says, noting that this attitude has been perpetuated by the criminalisation of same-sex relationships. “If laws were flexible, many would come out and the society would more easily accept us.”

Discrimination persists among healthcare workers

A 2022 study by Art & Global Health Center (ArtGlo) Africa, a Malawian NGO that harnesses the arts to promote social change, revealed low knowledge of LGBTQ+ issues among the general population. It also found that LGBTQ+ communities lack support networks and have limited knowledge of their own basic rights.

“But it’s not enough since there are many healthcare workers out there who are still homophobic... The community needs this kind of awareness too.”

Crucially, the report revealed more discrimination against and abuse of LGBTQ+ people in healthcare clinics than anywhere else; this discrimination includes lack of attention and delayed or denied medical attention.

Likewise, the Malawi National Strategic Plan for HIV and AIDS 2020–2025 reports that men who have sex with men experience stigma and discrimination, which prevents them from accessing HIV prevention services and care.

ArtGlo initiated training through a series of workshops to help change the attitudes of healthcare workers towards LGBTQ+ communities. ‘Umunthu’—a pan-African concept that reflects the notion that no single person exists as an isolated individual, but rather as a member of their broader community—was a key area of focus.

Zoa says there was a noticeable improvement in the attitude of healthcare workers after the workshops began. But discriminatory beliefs remain stubbornly hard to shift, which makes it more difficult to break down stigma.

“There are many healthcare workers out there who are still homophobic. The community needs this kind of awareness too,” Zoa says. Of a colleague who had his house burnt down after his sexual orientation became known, he says: “We live in fear.”

Alexander Kampheta, the executive director of the Centre for Key Populations and Rights, believes Malawi’s homophobia comes from a generalised and deep-rooted belief that it is a ‘God-fearing nation’.

“Our laws are also discriminatory, leading people into homophobia, labelling [LGBTQ+] as satanic or demonic,” says Kampheta, who was chased out of a rented house for his advocacy work. He was also physically assaulted for participating in Malawi’s first ever pride parade in 2021.

Kampheta notes hypocrisy where on the one hand, Malawi’s Ministry of Health prioritises key populations like LGBTQ+ communities in efforts to eliminate HIV, and on the other hand, laws criminalise same-sex unions. “Government systems aren’t speaking to each other,” he says. “The systems are supposed to [promote] awareness to make people understand that being [LGBTQ+] is inborn and not a choice. This may remove stigma associated with sexual orientation.”

Changing minds and promoting acceptance

Beauty Majawa, a healthcare worker at Mwanga Health Centre in Phalombe district in southern Malawi who undertook the ArtGlo training, says that most LGBTQ+ people who present to her with STIs hide their sexual orientation because of previous negative experiences with healthcare workers.

"The Uumunthu approach believes that the system is comprised of individuals and if we change individuals, we can change the system because systems are made by people.”

Even if they were to come forward, the centre’s internal systems only recognise men and women. “This makes it difficult for inclusivity or record keeping,” Majawa says.

She says including LGBTQ+ issues in medical training is one way to impart knowledge on healthcare workers to help eliminate discrimination and embrace diversity.

“Before ArtGlo training, I had so many questions. The training mentally prepared us to handle such patients,” Majawa says.

Rodger Phiri, the executive director of ArtGlo, agrees that stigma is often driven by lack of awareness and understanding of LGBTQ+ communities. Often, healthcare workers “don’t even know who [LGBTQ+] people are,” he says. “It seems these issues aren’t even taught at colleges.”

Phiri says the umunthu approach is slowly helping to bridge these gaps. “The umunthu approach believes that the system is comprised of individuals and if we change individuals, we can change the system because systems are made by people,” he says, explaining that the training aims to empower healthcare workers and facilitate development of ‘action plans’.

Chasing the root cause of homophobia

Human rights experts believe that although homosexual people have always been present, many African communities are homophobic due to a deep-rooted belief that homosexuality is inherently wrong and punishable. This has been cemented by another powerful institution: religion.

“If a person who engages in anal sex comes to hospital with issues that reveal their identity as homosexual, then stigma distorts how a health provider receives and attends to them,” Kangaude says.

Sexual and reproductive justice expert Dr Godfrey Kangaude, the executive director of Nyale Institute for Sexual and Reproductive Health Governance, says the influence of colonialism coupled with Abrahamic religions and African cultural values drive homophobia. Among healthcare workers, a perceived sense of moral responsibility can perpetuate stigma.

“If a person who engages in anal sex comes to hospital with issues that reveal their identity as homosexual, stigma distorts how a health provider receives and attends to them,” Kangaude says. “They may be disgusted or take an approach that is influenced by moral views about the issue, rather than treat the person as any other patient or client seeking services.”

Thuthukile Mbatha, the regional advocacy lead for AIDS and Rights Alliance for Southern Africa (ARASA), says homosexuality is often viewed as a Western phenomenon, and explains that some African people reject the idea that sexual orientation is determined at birth.

“Discrimination against persons who identify differently from the norm poses threats to such entitlements including bodily autonomy and integrity,” she says. “This means that they cannot make decisions about who they wish to date, whether or not they wish to marry, and whether or not to have children. They struggle to access sexual and reproductive health services, treatment and care for HIV and STIs, and even protection from gender-based violence.”

Institutions hold the balance of power

So influential is religion that Chikondi Chijozi, who is responsible for the criminal justice program at the Southern African Litigation Centre (SALC), says that “the problem starts from here.”

In 2023, Christian and Islamic religious leaders led street protests against same-sex marriage across the country, as a Dutch citizen and Malawian transgender woman challenged laws against same-sex relations in the Constitutional Court. In June, the court dismissed the case.

“The fundamental of religion is love but it’s strange that our churches don’t show that towards [LGBTQ+] communities. If our churches don’t embrace diversity of people, then we have a problem,” Chijozi says.

She believes Malawi’s two major religions have the power to enact change and improve outcomes for LGBTQ+ communities—in healthcare settings and in daily life. “If churches embraced LGBTQ+, there would be change because they have lots of influence…families feel ashamed of their own because they are always afraid of what the church would say,” Chijozi says.

Outside the sphere of religious influence, she says there is a need for legal reform, community engagement, and demystifying misinformation, explaining that the umunthu approach is an effective starting point that helps to “open people’s minds.” “It’s an effective way of dealing with issues,” Chijozi says.

Kangaude recommends a greater focus on human rights—an agreed-upon system of values that sets out how we relate to each other as human beings. These values, he says, imply that society should let people be who they want to be and let them express themselves in a manner they would like without anyone forcing them to do or be one way or the other.

“Human rights don’t require us to be happy with whatever others are doing. We are diverse. Human rights require tolerance and letting people be, so that we can live in harmony,” he says.

With Malawian president Lazarus Chakwera indicating that it will be up to the country’s people to decide whether to legalise same-sex marriage through a referendum, there is hope for a gradual shift in societal attitudes towards acceptance of diversity—and better healthcare outcomes for LGBTQ+ communities.

*Name changed at interviewee’s request    


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