A qualitative study on the access to health services of LGBTI people in Cambodia: Case Studies Phnom Penh, Cambodia March 2018 1 Introduction.................................................................................................................................. 3 Objective ....................................................................................................................................... 3 Glossary of Terms ....................................................................................................................... 3 Methodology ................................................................................................................................ 4 Summary of informants.............................................................................................................. 5 Findings ........................................................................................................................................ 5 Bibliography ................................................................................................................................. 6 Appendix: Case Studies ............................................................................................................. 8 A story of transgender woman ............................................................................................................ 9 A story of transgender man .............................................................................................................. 11 A story of MSM ................................................................................................................................... 13 A story of clinic counselor................................................................................................................. 15 A story of a clinic doctor (I).............................................................................................................. 17 A story of a medical doctor (II) ....................................................................................................... 19 2 Introduction This qualitative study consists of six case studies undertaken on the access to health services of LGBTI people in Cambodia, with a particular focus on best practice in LGBTI-inclusive health care provision. The development of the case studies was undertaken by Piotr Pawlak (Senior Gender Consultant, World Bank) and Bunthorn Kong (Translator/Research Assistant) and guided by Erik Caldwell Johnson (Senior Social Development Specialist, World Bank). This research team has significant experience both in researching development and LGBTI issues in Cambodia and internationally. In addition to their research expertise in this area, the team included local Cambodian activist identifying himself with LGBTI identities. Objective The case studies aimed to document the positive experience in accessing health care services by LGBTI individuals, and capture best practice and lessons learned in relation to health care provision for LGBTI people in Cambodia. It is hoped that the case studies will be utilized in training of health care professionals in Cambodia. Glossary of Terms Assigned sex at birth - the sex (male or female) assigned a child at birth, based on the child’s anatomy. Also referred to as birth sex, natal sex, biological sex, or sex. Bisexual - a person who is sexually or romantically attracted to or has sex with people of more than one gender. Gay - sa person who is primarily sexually or romantically attracted to or has sex with someone of the same gender. Commonly used for men. Gender - The social attributes and opportunities associated with being male and female. It encompasses the relationships between women and men and girls and boys as well as the relations between women and those between men. Gender Expression - the way a person acts, dresses, speaks, and behaves (i.e., feminine, masculine, androgynous). Gender expression does not necessarily correspond to assigned sex at birth or gender identity. Gender Identity - person’s internal sense of being a man/male, woman/female, both, neither, or another gender. Most people have a gender identity that is the same as the sex they were assigned at birth (e.g., a person assigned female at birth and who identifies as a woman). Heterosexual (straight) - sexual orientation that describes women who are emotionally and sexually attracted to men, and men who are emotionally and sexually attracted to women. 3 Intersex - an umbrella term for people born with sex characteristics, such as physical, hormonal, or chromosomal features that do not fit typical binary notions of male and female bodies. Intersex persons may have any sexual orientation or gender identity. Lesbian - a self-identified woman who is sexually or romantically attracted to or has sex with other women. MSM - Men who have sex with men. They may or may not identify as “gay� or “homosexual.� Sexual Orientation - tells you how a person characterizes their sexual and emotional attraction to others. Common words to describe sexual orientation are: Heterosexual (straight), lesbian, gay and bisexual. SOGIE - sexual orientation and gender identity and expression. Stigma - opinions or judgments held by individuals or society that negatively reflects on a person or group. Discrimination occurs when stigma is acted on. Transgender - an umbrella term for people whose gender identity or expression differs from the sex assigned at birth. Transgender identity does not depend on medical procedures. It includes, for example, people assigned female at birth but who identify as a man (female to male or transgender man) and people assigned male at birth but who identify as a woman (male to female or transgender woman). Methodology The case studies commenced in January 2018 and were completed in February the same year. The senior gender expert and local research assistant conducted semi-structured ‘life-story’ interviews with 3 informants who identified with LGBTI identities and 3 health care providers. The researchers followed a process of purposive recruitment (Sullivan & Losberg, 2003), seeking to recruit a diverse range of LGBTI informants with different socio-economic, educational, and professional backgrounds. Given that the research team has extensive connections and networks within LGBTI community in Cambodia a snowballing method of recruitment (Sullivan & Losberg, 2003) was employed. This recruitment strategy of drawing on existing networks had both strengths and limitations. Regarding the strengths, this approach enabled the team to quickly access difficult-to-reach stories, and was appropriate given the sensitivity of the research topic for research participants. However, this approach also had limitations, for example the research team was unable to locate sub-groups of LGBTI spectrum such as bisexual or intersex individuals, or specific groups of interest outside Phnom Penh (with one exception in Siem Reap). Two semi-structured interview questionnaires were developed: one for LGBTI clients of health care services and one for health care service providers. The interview questions focused on the individual experience in accessing or providing health care service to LGBTI people. All informants consented to having their interviews recorded, and these were subsequently transcribed verbatim by experienced translator. 4 The analytic method used by the research team was two-fold. First, we employed life-story method to capture critical moments in accessing or providing health care service among participants (Riley & Hawe, 2005; Hunter, 2010), highlighting positive experiences and best practice, as well as areas of resilience in their lives. We constructed condensed stories, which contained a number of direct quotations from the informants, in order to evoke what the essence of such experiences was. Secondly, we used a thematic approach to analysis that sought to identify common or recurring patterns in the interviews. Thematic forms of analysis offer an “accessible and theoretically flexible approach to analyzing qualitative data� (Braun & Clarke, 2006, p. 77) and are widely used analytic methods in social research (Braun & Clarke, 2006; Frith & Gleeson, 2004). Our analytic procedure was as follows: • During the case study development period, the research team met regularly to share thoughts about the data. • The research team then began reading through the informants’ interview data and identifying key themes in relation to the research questions around LGBTI’s experiences in access to health care and health workers service provision in Cambodia. Analysis was done in order to identify and highlight elements or approaches to LGBTI-inclusive health care provision. • After identifying individual themes among informants we went back to the transcripts to locate direct quotes that captured the nature of the informants’ experiences. • Six individual case studies were then finalized. Summary of informants # Name Nickname Age Date and place of Employment/ SOGIE-status interview Occupation LGBTI Individuals 1. KeoRomdoul Chhorvin 48 24 January, 2018; Unemployed TG Female Phnom Penh 2. Durng Srey Pich Daro 28 27 January, 2018; Volunteer TG Male Phnom Penh 3. Chen Long 25 28 January 2018; Tuk-tuk driver MSM Sothearlong Phnom Penh and student Name Nickname Age Date and place of Position Place of service interview provision Health Care Professionals 1. Dr. Tim Sotheara Dr. 52 31 January 2018; Medical doctor Chouk Sar I clinic (male) Khemera Phnom Penh 2. Dr. Mao Vannak Dr. Chang 55 6 February 2018; Medical doctor RHAC clinic (male) Phnom Penh 3. Mr. Deip Naray Nary 38 7 February 2018; Health counselor RHAC clinic (male) Siem Reap Findings 5 LGBTI people are very diverse. In addition to being LGBTI, they may be any race, ethnicity, religion or socio-economic background. All of these factors, as well as other social markers, can also affect their health care experience. In order to provide services and care to LGBTI people in the most effective way, health care service providers must be able to understand how LGBTI people’s identities, experiences, and relationships with the world around them might affect their health. Such understanding is crucial in improving access to health services for LGBTI clients. The findings of this research are based on interviews conducted with six informants (three with LGBTI individuals and three with health care providers) in two cities (Phnom Penh and Siem Reap) in Cambodia. The research focused on documenting the positive experience in accessing health care services by LGBTI individuals in Cambodia, and capturing best practice and lessons learned in relation to LGBTI-inclusive and friendly health care provision. Each case study highlights a set of specific approaches - attitudinal and behavioral practices – in providing LGBTI-inclusive and friendly health care service. A summary of the approaches s presented below1: 1. Displaying and maintaining positive, welcoming, respectful, non-discriminatory and non-judgmental attitude towards LGBTI clients; 2. Providing health care to LGBTI clients that is free of prejudice and judgment and treating all clients and their family members equally regardless of their SOGIE- status; 3. Building personalized, positive relationships based on confidence and trust, respect and collaboration between LGBTI clients and health professionals; 4. Investing in training, capacity building and knowledge expansion of health care service providers about SOGIE and LGBTI-specific health needs, risks and vulnerabilities; 5. Conducting sensitization of health care service providers about gender, gender equality and SOGIE-related issues; 6. Recognizing, acknowledging and respecting diverse sexual orientation and gender identity and expression and related attitudes and behaviors of LGBTI clients; 7. When addressing LGBTI clients, using pronouns that reflect client’s gender identity (as opposed to sex at birth only) or using nicknames or gender pronouns that are preferred by the client; 8. Making LGBTI-specific health information and education materials available at the point of service including about patient’s rights and services available specifically to LGBTI population; 9. Making low cost or free health care service available particularly for economically disadvantaged LGBTI clients. Bibliography Frith, H., & Gleeson, K. 2004. Clothing and embodiment: Men managing body image and appearance. Psychology of Men & Masculinity, 5(1), 40-48. 1 It is important to note that while contextualized and specific, the list is not exhausting. 6 Braun, V., & Clarke, V. 2006. Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101. Hunter, S. V. 2010. Analyzing and representing narrative data: The long and winding road. Current Narratives, 2, 44-54. Sullivan, G., & Losberg, W. 2003. A study of sampling in research in the field of lesbian and gay studies. Journal of Gay & Lesbian Social Services, 15(1-2), 147-162. Riley, T. & Hawe, P. 2005. Researching practice: The methodological case for narrative inquiry. Health Education Research, 20(2), 226-236. 7 Appendix: Case Studies 8 A story of transgender woman Chhorvin is a 48 year-old transgender woman who was born in Mondulkiri Province. She finished her schooling at Grade 7, and in 1993, she moved with her family to Phnom Penh in pursuit of work . She has been living in the city since then. Currently, she volunteers at a local non-governmental organization, which provides education to the local key affected population2, predominantly lesbian, gay, bisexual, transgender and intersex (LGBTI) Cambodians. About 3 years ago, Chhorvin was in a relationship with a 23 years old male, but the relationship did not last. Chhorvin’s safety net – the family that she stayed with - was opposed to the relationship. She was pressured to break off the relationship, as the relatives did not recognize her and her male partner as a couple. "I married my husband who was young and handsome, but my family did not recognize our relationship." Several months ago, Chhorvin was experiencing a reoccurring health condition in her reproductive system. She did not, however, go to a doctor. Instead, she decided to visit a local pharmacy and self-medicate. Weeks had passed and her condition was not getting better. She was unable to volunteer and was suffering physically. Around the same time, a health outreach worker came to her community to provide an orientation about a nearby public health clinic and the services available. At first, Chhorvin did not trust the counselor. She has experienced some stigmatization and discrimination in the past from health workers in public health centers and since then does not have confidence in the centers. She said that the mistreatment and negative judgment she received has impacted her emotionally and psychologically. She felt betrayed and disrespected as a transgender person. “They looked at me as I am from a lower level of society. They did not recognize me as a woman and disregarded me as transgender. This is why I don't go to doctors. When I am sick, I only go to a local pharmacy where I can buy any medicine I need.� She recalled experiences from the last year, when she visited several other public health clinics and felt pre-judged by the staff. She explained that general population often perceives LGBTI people as a drug user and HIV-positive persons. According to her, she is ‘more easily detected’ by the way she dresses and behaves and that gives away her TG-status and makes her more vulnerable to stigma. Secondly, at other clinics in the past her experience was not always a satisfying one. On several occasions, she was made to wait longer for her appointments, and sometimes was asked to ‘behave and express herself’ not as ‘who she thinks she is’. She was also asked to pay approximately US$ 30 for a regular health check-up, something that, as suggested by Chhorvin, may have been a ‘penalty’ for being TG. This was always a considerable expense for her, and often it meant making a choice between food on the table or a visit to the clinic. However, as her health condition was not getting any better, she had no choice but to overcome her fear of future discrimination and reconsider a visit to the nearby clinic. She spoke with the community outreach worker, who happened to also be a TG woman, and 2 The term key affected population (KAP) is commonly used to describe gay men, men who have sex with men (MSM), lesbians and transgender (TG) people, injecting drug users (IDU) and entertainment workers (EW). 9 received a referral slip for a health assessment. The counselor informed her about the services available at the clinic and that the check-up would be free of charge. The next morning she went to the clinic. "The reason I went to the clinic was only because my health was really bad. I also felt more comfortable after talking to the counselor, who like me was TG, and promised me that the service will be free.� The encounter with the TG outreach worker and the subsequent visit to the clinic was a very important experience for Chhorvin for two reasons. Firstly, this is because of the non- judgmental and compassionate TG community-based outreach worker, who provided clear information about the services available. Secondly, because the service was free of charge, as the clinic runs a special HIV/AIDS, sexually transmitted diseases (STD) and other venereal and communicable disease prevention and education project, with people that are most at risk. "The clinic helped me to get my health back at the lowest cost and sometimes for free. I can save some money for other expenses. I think this is very important because many TG in Cambodia are very disadvantaged: they don't work and don't have any money to survive yet their health problems are the same like among other Cambodians.� She also added: “If there would be no low-cost and friendly health care service for TG people they will face economic crises. When they are sick, they can’t work. When they don't work, they have no money for food or a place to stay. Then they run into troubles and many difficulties.� After the experience at the clinic, Chhorvin has gone back several times in the past three months. She is open about her gender identity to the clinic staff, and when needed, she also discusses her sexual behavior with the doctor, as she is a sexually active person. She said, the clinic staff recognize and acknowledge her as a transgender woman and provide service that is no different than that provided to non-LGBTI patients. The positive experience has also prompted Chhorvin to bring her current partner for a health check-up and to speak to other TG, lesbian and gay friends about the need to see a doctor rather than self-medication. What works – Good Practice • Building positive relationship with LGBTI clients through direct communication about unique health needs of LGBTI people and information sharing about appropriate services available to them; • Making low cost or free health care service available particularly for economically disadvantaged LGBTI clients; • Maintaining non-judgmental and respectful attitudes towards LGBTI clients from the registration and check-in to medical examination, diagnostic and the follow-up. 10 A story of transgender man Daro3 is 28 years old. As long as he remembers, Daro has known that he was born in a female body, but wanted to be a man. He grew up in Phnom Penn, where he graduated from Grade 12. Currently, Daro is employed as a cashier in local karaoke entertainment bar. A few months ago, Daro experienced some pain in his reproductive area and his menstruation was not regular. He felt sick and decided to, without prior referral from a community outreach worker, seek services at the nearby clinic. Although Daro is connected with the lesbian, gay, bisexual, transgender and intersex (LGBTI) network in Phnom Penh, he did not know that the clinic close to his house provides health services to the LGBTI people. He thought it was a general management center for HIV/AIDS and sexually transmitted diseases (STDs) for the general population. Only when a friend gave him a booklet about the clinic, did he learn about their LGBTI- specific services. As a walk-in, Daro needed to complete the initial registration process. He was asked about personal details, including his birth name and the name he wanted to be called by, and was given a wait number. Although Daro still passes as a female and his official identification card (ID) bares female name, the front desk assistant called him by his male name. Then, a nurse at the front desk offered some water and provided information and printed materials about the services provided by the clinic. From the booklet, Daro learned that men who have sex with other men (MSM), gay men, lesbians and transgender (TG) people are welcomed at the clinic and that, like the rest of Cambodians, they have the same rights as patients. This was something new, as he has heard from his friends that they fear revealing their sexual orientation or gender identity and expression in health care centers, anticipating negative attitudes and judgment from health care providers. "The first time that I entered into the clinic the receptionist was very beautiful and [she] asked me with a very friendly and soft voice what I came for? She gave me very detailed information about the services that were available". At the clinic, he did not have to wait longer than other patients. A nurse invited Daro to an examination room based on his wait number and asked him whether he preferred a male or female doctor. She explained that as a transgender person he could choose to speak either with a female or male doctor. Because Daro is still a biological female, he chose a female doctor. “The doctor asked me about the condition. She used the equipment softly and provided sensitive check up. She had understanding towards my identity. I felt very comfortable and safe. After the examination his need to wait around 5 minutes and then he went to get the medication in the dispensary room�. During the examination, Daro felt well attended. The doctor was familiar and comfortable with providing an examination for a TG person. She also addressed Daro using the ‘he’ 3 For the privacy and confidentiality reasons, the name has been changed. 11 pronoun, which gave him a sense of acknowledgment and recognition of his true gender identity as opposed to his sex at birth. After the examination, medical assistant called Daro to a separate room, where he received the medicine and was informed how to use it. He also received counseling about female sexual and reproductive health and additional printed materials specifically about TG-specific health risks. "I felt very welcomed. The nurse treated me with respect and in a friendly manner. She also used my male name and not the female name from the ID card. The facility and the quality of treatment were competent. The doctor and nurse were very professional and sensitive. " A few weeks have passed and Daro has forgotten about his follow up. He only remembered the appointment when a clinic staff called him to remind him about the missed check-up. He returned to the clinic for the second visit and he had a similar positive experience, as opposed to other public clinics he visited in the past, where he felt ignored and made to wait longer than others. When asked how he was treated at other clinics, Daro emphasized a lack of recognition of gender identity. Many health care providers he met in his life were clinical professionals, but not many have recognized and acknowledged his gender identity. He suggested that many health professionals in Cambodia are not fully aware of what gender identity is, are uncomfortable and have difficulty communicating with LGBTI people, and often have prejudices towards LGBTI clients based on negative cultural and traditional beliefs. He hopes that other LGBTI people in Cambodia will have access to and receive health care services that also accommodate their sexual orientation and gender identity and expression. What Works - Good Practice: • Making LGBTI-specific health information and education materials available at the point of service including about patient’s rights and specific services available to LGBTI population; • When addressing LGBTI clients, using pronouns that reflect client’s gender identity (as opposed to sex at birth only) or using nicknames or gender pronouns that are preferred by the client; • Treating all clients and their family members equally regardless of their SOGIE-status; • Providing training and equipping health care service providers with knowledge about SOGIE and the LGBTI-specific health risks, needs and vulnerabilities. 12 A story of MSM Long is a 25-year old male, who identifies himself as a man who sex with men (MSM). Long moved from Kampot Province to Phnom Penh city with his 2 brothers to pursue a bachelor’s degree. He lives in a small rental room on the outskirts of the city, and while going to school, he works part time as a tuk-tuk driver. Recently, Long did not feel well. He felt some itching in his genital area and had a high fever, which stopped him from gong to school and working. He decided to look for a health clinic that is near to his home. “I really needed to go to a clinic because of the itching and the fever. I decided to visit Chouk Sar Clinic because it was near my place. I did not have a referral slip from anyone�. Long arrived in front of the Chouk Sar clinic. There was a security guard who gave him a parking slip for his motorcycle and then directed him inside. As he entered the clinic, he quietly approached the registration desk. In the past, had had some bad experiences, where staff of other health care centers would ask him in front of others questions related to his sexual orientation and sexual behavior. Because of his masculine appearance, he would lie about his sexual preference for men, and was disappointed and uncomfortable with such treatment. At this clinic however, the receptionist registered him without directly asking about his sexual preferences or sexual behavior, but rather, she began by providing him with very detailed information about the health services available. She then registered him and asked, generally, about the health service he needed at that moment. "I felt very comfortable when I was talking to the receptionist and other clinic staff, but I do not remember who they were. I remember they were friendly with a positive attitude and smiles." After the registration, Lao was asked by a nurse to go and meet the doctor, who invited him into the examination room. The doctor conducted a routine check-up and then provided Long with information about risks related to sexual behavior, and safe-sex practice. "I walked to the first floor of the clinic and I looked around the facility. It looked clean. I saw some posters about sexual behavior and sexual health of gay people or we can say MSM. There were also pamphlets about HIV/AIDS prevention, particularly among LGBTI people. I decided to disclose my sexual orientation to the doctor.� During the check-up, Long felt comfortable enough to disclose the fact that he engages in sex with other men and transgender women. He also shared with the doctor some of his sexual encounters from past year, which as he indicated, “were a reason for the itching�. Despite being detailed about his sexual encounters, the doctor provided him with quality health service including counseling about condoms and lubricants use. Long felt there was no judgment or prejudice towards him having frequent, often unprotected, sex with other men. “The doctor understands the behavior of men who have sex with men. He knew things about the sexual behavior of gay people. He gave me good advice to use condoms and lubricant during sexual 13 intercourse. He told me to come and check my health again and to take the HIV test every three months.� Normally, health care centers charge for similar health services without referral slip from outreach workers. Despite not having a specific referral, Long paid only one US dollar for the registration. This is because the clinic receives funding for HIV/AIDS and STI prevention, care and treatment from international donors through the government. In additional, Long also received free medicine and some education materials for MSM. “I was happy with the service received in the clinic. I was very surprised. I never thought that I would pay only 1 dollar and that I can access primary health care service in Phnom Penh city that is friendly to MSM. Many of my friends said that MSM are not always welcomed and that everything in Phnom Penh is expensive as compared to the provinces.� After several days of treatment, Long felt much better and was able to go back to school. He also returned to his part-time job as a tuk-tuk driver. He emphasized that he was not aware that the Chouk Sar is MSM-friendly and that the clinic provides education materials specific to MSMs. He was also surprised with the very positive and welcoming attitude of staff towards him, “something different�, as he described from other health care centers he visited in the past. When asked about the most positive element of the experience at the clinic he mentioned, “I was able to disclose my sexual orientation and I was not judged. I did not tell anyone at other clinics. I received a good service.� Since people having non-heterosexual relationships are not always able to specify who they are sexually active with, it reduces their chances of being able to access health services they need without going to an LGBTI-specific health care center. Long hopes that other MSMs in Cambodia can also have positive experiences as he did. He hopes that, like him, others would be able to disclose their sexual orientation or gender identity and expression during their health check-ups. He hopes that the confidentiality as well as the friendliness and the respectful attitude of staff towards other gay, MSM and transgender people, and key populations, will be a standard for all health care centers in Cambodia. “Because of the respect and non-judgmental staff attitude I received, I will come back for the follow up check-up.� What Works - Good Practice: • Making LGBTI-specific health information and education materials available at the point of service including about services available specifically to LGBTI population; • Maintaining positive, welcoming and respectful attitude towards LGBTI clients and providing health care services that is SOGIE-sensitive; • Addressing SOGIE-status and LGBTI-specific health needs in non-judgmental, respectful and confidential way. 14 A story of clinic counselor Nary4 is a 38 years old male living in Siem Reap. He graduated with a bachelor’s degree in culture and fine arts, but for the past 10 years he has been working as health counselor at a local clinic in Siem Reap. He predominantly works with key affected population5 (KAP), particularly men who have sex with men (MSM) and transgender (TG) people, who seek primary health care as well as management and care of HIV/AIDS and sexually transmitted diseases (STDs). " I am very happy to work as counselor directly with the MSM and TG population because I am LGBTI myself. I understand their concerns and want to help the community by providing messages and information specific for the MSM and TG people in Siem Reap, which is my hometown". In the 10 years of being at the clinic, Nary has learned a great deal about LGBTI-specific health needs and vulnerabilities. This is particularly with regard to risky sexual behavior, substance abuse and mental health among LGBTI people in Cambodia. Over the years, he also became very well connected with the LGBTI community in Siem Reap by attending various seminars, outreach and advocacy events. He was also trained by other medical professionals in primary sexual health including HIV/AIDS and STD care and management, and was taught counseling skills. Most of the training courses that Nary attended focused on KAP, with particular focus on MSM and TG. He now understands the level of sensitivity and personal attention that is needed to ensure that LGBTI people access health care services. "I am not a medical doctor but I am still able to provide care ad treatment to MSM and TG people. This is because of the capacity building and training I received from the clinic." Nary is proud of the fact that many MSM and TG people access the clinic in Siem Reap. The main reasons behind this, as he explained, are that the clinic has a good reputation as LGBTI-friendly, and because the staff, including himself, are knowledgeable about and sensitive to the needs of KAP. He said that the key to ensuring equal access to health care for LGBTI people, is good communications with them, sensitivity and inclusiveness: “it is about the comfort level and confidence to talk about LGBTI-specific health problems.� According to Nary, if clinic staff are committed to health provision to LGBTI people in the community, this facilitates access. "I consult many of MSM and TG individual. I am a gay male myself. People trust me and relate to me. They can always call me up for advice when they have any health concerns. Sometimes I also deliver information to them via text messages, and they can respond to me using phone messaging. I often then communicate with a doctor in the clinic, who prescribes appropriate medication." Nary explained also that providing access to health care provision for LGBTI is not only about the number of clinics for KAP. It requires extra time and human effort. Due to the societal stigma around being LGBTI, many Cambodian MSMs and TGs (as well as gay men 4 For the privacy and confidentiality reasons, the name has been changed. 5 The term key affected population (KAP) is commonly used to describe gay men, men who have sex with men (MSM), lesbians and transgender (TG) people, injecting drug users (IDU) and entertainment workers (EW). 15 and lesbians) are discriminated against in the health sector – whether when seeking or when receiving care - in addition to discrimination in education, employment and other sectors. Thus, they are reluctant to access public health services. Those who can afford it, access primary and specialized health care at private clinics, but that number is very low. Others, particularly those LGBTI who are poor and live in rural communities, don’t seek, and in consequence, don't access the health care they need. This, in turn, creates a host of devastating individual health consequences and negative social impacts. Nary explained that to work well with MSM and TG people, as compared to the non- LGBTI population, health care providers must, firstly, be sensitized and aware about what sexual orientation and gender identity and expression (SOGI) is. They must better understand the specific LGBTI health vulnerabilities and their needs, and what makes this group different from the non-LGBTI population. It requires building close relationships with individual LGBTI clients that is based on trust and confidence. Nary said that training courses that build capacity of health care providers to work with LGBTI people and equip them with knowledge and skills is an effective strategy to ensure equal access to health care for all Cambodians. "Personal communication is the best way to reach MSM and TG people to access health services. I have a positive and non-judgmental attitude, I am sensitive to personal experiences of LGBTI clients. I build trust and good communication with them. It is an essential part of the equal access". What Works - Good Practice: • Building personalized relationship with LGBTI clients based on trust, respect confidentiality and confidence; • Maintaining a non-judgmental attitude that makes LGBTI clients feel safe and included and recognizing and respecting different gender behaviors, identities, and expressions; • Providing training and equipping health care service providers with knowledgeable and sensitivity about SOGIE and the health needs and vulnerabilities of LGBTI clients. 16 A story of a clinic doctor (I) Dr. Khemera6 is a 52-year old male health professional. He graduated as a medical doctor from the Technical School for Medical Care in Cambodia and for approximately 8 years has been working as a doctor at a local public health clinic at Phnom Penh. The clinic provides primary health care including HIV/AIDS and sexually transmitted diseases (STD) care, antiretroviral therapy (ART) to the general population and the local key affected population7. Dr. Khemera is an experienced health practitioner particularly providing services to gay men and men who have sex with men (MSM), lesbians and transgender (TG) people. "I turned to work with MSM and TG people because I know that they are at increased sexual health risk, and I want them to become a low-risk group for HIV infection." During the eight years at the clinic, Dr. Khemera attended to many lesbian, gay, bisexual, transgender and intersex (LGBTI) Cambodians who suffer from specific health problems including violence, sexual health including HIV/AIDS and STDs, substance abuse, mental health and suicides, among other health concerns. Many of the people he met also suffered from fear of stigmatization that prevented them from identifying themselves as lesbian, gay, bisexual, or transgender. Many of the LGBTI people he met did not seek health care because of prior negative experiences of discrimination, mistreatment and verbal abuse from health care professionals. In the past, Dr. Khemera received training from The National Centre for HIV/AIDS, Dermatology and STDs (NCHADS) on the KAP-specific sexual health risks and behaviors. However, during his tenure at the clinic, he also learned a great deal of information from the LGBTI patients themselves, who sought primary health care, STD and HIV-related health services at the clinic. He learned that many LGBTI people in Cambodia experience stigma and discrimination from health care professionals when seeking health care services. They face inadequate access to competent care that is aware of and sensitive to their specific health needs and vulnerabilities. Many of them are also often uninsured including same-sex who live together without access to IDPoor as a result of not being recognized as ‘family’. "In addition to the training from NCHADs, I have learned about the sexual behavior of MSM and TG persons through the treatment and counseling them.� Dr. Khemera is well known in the LGBTI community in Phnom Penh. He provides LGBTI clients with sensitive and confidential care and treatment they need including counseling and information about HIV/AIDS and STDs prevention and other LGBTI-specific health risks and vulnerabilities. " I study and read a lot about the non-LGBTI and LGBTI specific health needs and vulnerabilities. I am also interested in cultural factors that may affect their health care, including beliefs, attitudes, and behaviors of health care providers. I have attended a training course about specific health needs and of KAP in Cambodia� 6 For confidentiality reasons, the name was purposely changed. 7 The term key affected population (KAP) is commonly used to describe gay men, men who have sex with men (MSM), lesbians and transgender (TG) people, injecting drug users (IDU) and entertainment workers (EW). 17 Based on his experience, Dr. Khemera shared his personal experience as to how to provide an inclusive and friendly service to LGBTI populations, particularly MSM and TG clients, who often face the highest rates of discrimination and stigma in access to health services. He explained that quality services should include recognition of the patient’s sexual orientation and gender identity and expression. His experience shows that a non-judgmental and non- discriminatory attitude is essential when treating LGBTI patients. It is about building a rapport with the LGBTI client and establishing a proper channel of communication based on confidentiality and respect towards LGBTI clients. It helps to build a close patient-health service provider relationship with MSM and TG people and other LGBTI individuals. "I always treat all clients (included MSM and TG) who come to the clinic equally. They are all my patients and should be cared for equally not matter what their gender or sexual orientation is. "I always tell MSM and TG people who come to the clinic to bring their friends and sexual partners to take an HIV test or to address any other primary health needs". What Works - Good Practice: • Investing in capacity building and knowledge expansion of health care service providers about SOGIE and LGBTI issues; • Building close relationship with LGBTI clients based on trust, respect, comfort and collaboration; • Recognizing and acknowledging diverse sexual orientation and gender identity and expression; • Displaying non-judgmental and non-discriminatory attitude when treating LGBTI clients. 18 A story of a medical doctor (II) Dr. Chang8 is a 55-year old medical doctor, who graduated from the Technical School for Medical Care in Cambodia in 1994. He has more than 20 years of experience in providing health care to Cambodia’s general population. Since 1997 he has worked at a clinic in the Toul Sangke commune in Phnom Penh city, which, among other clients, provides health care services to key affected population9 (KAP), particularly lesbian, gay, bisexual, transgender and intersex (LGBTI) Cambodians. "My age is only a number and the main thing is that I love my work and I try to do the best with my career related to my ability to provide good services to my clients. I started working in RHAC clinic 20 years ago, only 3 years after I graduated as a doctor from medical school in 1994. " Dr. Chang is experienced in providing health care including HIV/AIDS and sexually transmitted disease (STD) care to Cambodia’s KAP. He attended several trainings about the specific vulnerabilities and health needs of LGBTI people in Cambodia. It gave him a foundation to become more knowledgeable, more sensitive and more welcoming to LGBTI clients, as the population continues to face high rates of discrimination in access to health care and suffers from a disproportionate burden of chronic illnesses. Even for basic primary-care services, many LGBTI clients of health services are reluctant to visit providers that do not offer services specific to the LGBTI population. As a result, many LGBTI people may delay or forgo seeking care to avoid what they fear will be an uncomfortable experience with clinical staff. He has established his career at the local health care clinic, where many LGBTI people, in additional to non-LGBTI clients, seek primary health care as well as HIV/AIDS and STD-specific services. "Like the non-LGBTI population, LGBTI people also seek to access to health services related to their sexual activity and other health issues including vaccination against hepatitis and Tetanus. Gay men and men who have sex with men (MSM) seek advice about premature ejaculation, erectile dysfunction, post exposure prophylaxis. Lesbians, like the rest of the female Cambodian population, seek advice and information about cervical cancer screening and emergency contraception human papillomavirus (HPV), and breast cancer screening.� Dr. Chang explained that while gay men, lesbians and transgender people seek health services in Cambodia, there are differences in the way they access and experience health care. He said that many LGBTI clients are hesitant to disclose their sexual orientation and gender identity and expression (SOGIE) for fear of stigmatization and discrimination. He said that, particularly, transgender women are cautious about having their check-ups particularly around their sexual and reproductive area, and do not always let the doctor examine them closely. It is different in comparison to non-LGBTI women, who generally feel more comfortable with medical check-ups. This, in turn, creates a set of difficulties for the medical staff to conduct proper examinations and provide adequate responses, diagnosis and treatment. 8 For the privacy reasons, the name has been changed. 9 The term key affected population (KAP) is commonly used to describe gay men, men who have sex with men (MSM), lesbians and transgender (TG) people, injecting drug users (IDU) and entertainment workers (EW). 19 "There was a TG women that came to a clinic with some issues in her reproductive health area. She was vey shy and uncomfortable to discuss and show us the condition.� Dr. Chang attributed the challenge to the fact that many of the TG clients have experienced some level of discomfort and inadequate health care, and even hesitation on the part of health professionals to conduct proper medical check-up. He explained that there are not many transgender-competent physicians in Cambodia and that many health care professionals lack awareness and sensitivity about diverse sexual orientations and gender identities and expressions (SOGIE) and do not have LGB and transgender-specific training. “We have to change our attitude and provide services to LGBTI clients with a friendly and warm attitude." Based on his experience in providing health care to LGBTI Cambodians, Dr. Chang shared a few lesson learned and best practices in ensuring adequate access to health care for the LGBTI population. In his opinion, it starts with communication and respectful attitudes towards people with diverse sexual orientations and gender identity and expression: building positive relationships based on confidence and trust between LGBTI clients and health professionals. This requires not only a certain level of professional knowledge related to LGBTI health risks and behaviors but also a certain level of personal awareness of, and sensitivity about, SOGIE and LGBTI in general. It can only be achieved through specific capacity building and sensitization training of every single health professional – from the front desk staff, to medical assistants, nurses, doctors and pharmacists and health care center management. " Health service providers should cooperate and communicate with LGBTI clients and should understand SOGIE. Communication and sensitivity is the key to quality access and the provision of health care to LGBTI individuals". What Works - Good Practice: • Maintaining respectful and non-judgmental attitudes towards LGBTI clients; • Building positive relationships based on confidence and trust between LGBTI clients and health professionals; • Investing in trainings about the specific vulnerabilities and health needs of LGBTI people in Cambodia; • Building capacity and sensitizing health care service providers about SOGIE and LGBTI issues; 20