Two years ago, Shivam Sharma rushed to a Mumbai hospital at 2:30 a.m. He'd had sex earlier that night with a man who was HIV positive. They'd used protection, but Sharma just wanted to be sure he was safe.
So he went straight to the emergency room and asked a junior doctor for a preventative dose of antiretroviral medicines, or PEP — post-exposure prophylaxis.
Hospital staff "were absolutely clueless," Sharma, 28, recalls. No one had ever asked for a PEP before, staff told him.
"They pulled out a massive manual on how to deal with sexually-transmitted infections and insisted I take something like 25 different tests," he says. They phoned a senior doctor at 3 a.m.
Sharma felt frustrated. He had to fight for a basic prescription.
It was just like the first time he got tested for HIV, back in college. He went to a posh health clinic, and the nurse yelled across the room, warning a colleague — and anyone else within earshot — to "be careful" of him.
The implication was that Sharma was dangerous and dirty because he had identified himself as "queer."
For more than 150 years, homosexuality was a crime in India. Section 377 of the Indian Penal Code, a British colonial-era law, banned sexual acts that were "against the order of nature." There have been prosecutions under the law. But more frequently, it gave police license to harass and blackmail gay men.
Section 377 drove generations of LGBTQ Indians into the shadows. It prevented many from fully embracing their sexual and gender identities. It complicated both patients' and doctors' access to information on LGBTQ-specific health issues. And it got in the way of access to vital medical care.
When India's Supreme Court ruled Sept. 6 to decriminalize homosexuality, modifying Section 377, it opened a new era for public health policy.
In its judgment, the court said the Indian constitution guarantees all Indians, including LGBTQ people, "the right to emergency medical care and the right to the maintenance and improvement of public health."
India's government has yet to announce any formal changes. Activists hope for major reforms to health policy, including mandatory sensitivity training for doctors and nurses at public hospitals and clinics, and new LGBTQ-specific chapters in medical school textbooks.
But they acknowledge implementation could take years.
Despite that first traumatic HIV test experience, Sharma kept seeing doctors for regular checkups and care.
But many LGBTQ Indians say they have long avoided doctors and hospitals altogether.
Some may self-medicate, taking over-the-counter drugs for sexually-transmitted infections without getting tested.
Some may visit homeopaths or pharmacists when they really need a doctor.
Others may hide their sexual orientation when they enter a hospital or clinic and then don't get the care they may need, like HIV testing, for example.
Despite the obstacles to getting appropriate and respectful care, it was almost unheard of for medical professionals to report a patient for violating Section 377. But for many patients, interactions with doctors and nurses were enough to leave them punished emotionally.
Twenty years ago, when Shashi Bhushan was a teenager, a dermatologist asked if he had a girlfriend and whether they were sexually active. Bhushan explained that he had multiple partners and was homosexual.
"Don't you think this is curable?" Bhushan, now 36, recalls the doctor asking. "I said, 'Well, it's not a disease.'"
His doctor believed otherwise. And some of India's most popular spiritual gurus preach the same thing.
Bhushan says acceptance and awareness of gay rights has improved a lot in the past 20 years, especially in cosmopolitan cities like the capital New Delhi, where he lives.
But Bhushan says he's terrified of getting ill while traveling in the countryside. "I am still scared to visit doctors in small towns and rural areas," he says.
When someone who is openly gay does visit a doctor, the doctor often prescribes so-called "conversion therapy," in which counselors try to "convert" someone from being gay, says Vinay Chandran, a peer counselor and director of Swabhava, an LGBTQ support group.
"I'm often left seething when I hear about the treatment LGBTQ people get at both public and private hospitals," Chandran says. "When these people eventually come to me for counseling, they're already scarred."
Given such experiences, it's no wonder people in India circulate crowdsourced lists online of LGBTQ-friendly doctors and clinics. But such efforts are informal.
"It has to go through word of mouth," says Arnav Srinivasan, a 38-year-old transgender man who has not undergone surgery.
Srinivasan, a market analyst in Bengaluru, has never in his life been to a gynecologist. He is already worried about reaching menopause — when such a visit might be medically necessary.
"I will be looking for an inclusive doctor who is open to talking about my sexuality and doesn't make me feel like a woman," he says.
While condoms are readily available in Indian drugstores, Section 377 made it difficult to educate LGBTQ people on how to use them correctly. One of the plaintiffs in the successful lawsuit that challenged the law was a health worker who was jailed in 2001 for handing out condoms to gay men. He was charged with abetting a crime.
"[Health workers] do need to have conversations about protection, but those couldn't happen because of Section 377," says Pallav Patankar, former director of programs at Humsafar Trust, a Mumbai-based nongovernmental organization that promotes LGBTQ rights.
Research shows that males who have sex with other males have a higher rate of HIV infection. In India, the national HIV infection rate is 0.31 percent, but among homosexual males, it's 4.3 percent.
Now that homosexuality is no longer a crime in India, health organizations need not worry about breaking the law when they promote safe sex and distribute condoms to high-risk groups in the LGBTQ community.
The Section 377 ruling is actually the second such Supreme Court decision in recent years that pertains to sexual minorities. In 2014, the court recognized transgender as an official third gender and legalized gender reassignment surgery, which is now offered by some top Indian hospitals. It also instructed state governments to make available gender-neutral public toilets.
But experts say progress on social acceptance has been slow. Gender-neutral toilets are scarce, and most hospitals in India have male or female communal wards, not private rooms, and lack spaces to accommodate people who do not conform strictly to male or female genders.
When Srinivasan, a transgender man, goes to a clinic, medical staff note his gender as "female" without asking him.
"They assume your identity. That really puts me off," he says. "The doctors really have to be educated about the spectrum of sexuality."
Officials at India's Health Ministry and Council of Medical Research did not immediately respond to NPR's requests for information or interviews on what they plan to do differently after the Supreme Court ruling.
"The [Supreme Court] verdict clearly suggests that the onus is on the government to disseminate [new guidelines] to public institutions, especially to law enforcement," which has been behind some of the harassment and blackmail of LGBTQ Indians in the past, says Dr. Sambuddha Chaudhuri, a public health expert based in Mumbai who has done research on HIV and sexual minorities. "There's been no official statement, which is surprising for a government which is so savvy on social media."
Prime Minister Narendra Modi heads a conservative, center-right party and is running for re-election early next year. He has not spoken publicly on Section 377 nor its revision.
"After the transgender ruling, the court mandated sensitization programs in schools and for police. But it's unclear how much public visibility there will be for future programs. The government might just do it quietly," Chaudhuri says.
Nonprofit groups may pick up the slack. Humsafar Trust spokeswoman Koninika Roy told NPR that her organization is planning to offer anti-discrimination workshops to Indian district courts and law enforcement agencies.
While gender and sexuality sensitivity training is common in many Indian corporations, it's often missing in hospitals and medical schools.
"There was almost nothing on LGBTQ health in my medical school textbooks, except for a mention of [people born] intersex" with aspects of both male and female genitalia, says Dr. Sangeeta Saksena, a gynecologist based in Bengaluru who went to med school in the late 1980s.
In 2001, Saksena co-founded an NGO called Enfold to provide sex education to college students and their parents.
"We need a complete revamp of our approach to sexuality and sexual health," she says.
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