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Health and human rights

Torture, ill-treatment, and sexual identity

n 18 September, a 16-year-old Egyptian boy was sentenced to 3 years imprisonment for alleged homosexual behaviour.1 Amnesty Internationals (AI) recent report on the torture and ill-treatment of lesbian, gay, bisexual, and transgender people highlights that such humanrights abuses, ranging from loss of dignity to assault and murder, are widespread.2 Much of this abuse is sanctioned by governments and society through prejudices, religious traditions, and discriminatory laws such as those limiting rights to freedom of expression and association. The AI report implicates health professionals not only as passive bystanders, but also as active perpetrators of abuses citing, for example, the use in the military of apartheid South Africa of discredited therapies aimed at repairing homosexual orientation. The concerns of lesbian, gay, bisexual, and transgender populations have long been neglected in humanrights agendas.3 Recognition is now growing that although constructions of sexuality and gender may vary, these people all over the world share experiences of stigma, discrimination, and ill-treatment. By identifying global patterns of abuse based on sexual orientation and gender identity, the AI report makes universal what have been perceived as local concerns and places these issues firmly within international human rights discourse. Attempts to rationalise discrimination through claims that diverse sexual

identities are foreign to cultural or religious beliefs are rightly rejected. Discrimination affects the health of lesbian, gay, bisexual, and transgender people in many ways.4 First, a social environment characterised by homophobia (negative attitudes toward gay men and lesbians), heterosexism (negation of forms of sexuality or relationships that are not heterosexual), and social isolation can be stressful, leading to poor physical and mental health. Second, heterosexism has resulted in marginalisation of these peoples health issues in public-health agendas. Third, health research can stigmatise people who are not heterosexual and contribute to discrimination and ill treatment. For example, the association of HIV/AIDS with gay men in the USA has been used to justify violations of gay peoples rights, such as segregation of prisoners with HIV, as part of public-health efforts to curb disease. Fourth, homophobia and heterosexism within health-care institutions can increase barriers to health care for lesbian, gay, bisexual, and transgender people and lead to substandard care. Also, despite the declassification of homosexuality as a mental-health disorder, some forms of sexual identity are still treated as diseases. For example, gender-identity disorders, a category that describes atypical or non-conforming modes of gender expression, is still included in the Diagnostic and Statistical Manual for Mental Disorders (DSM IV). Medicine

can thus function as a form of social control, as shown by the forced admission to psychiatric hospitals of lesbian, gay, bisexual, and transgender people in Russia and the Ukraine.2 In these and other cases, health-care providers put the interests of the state before the interests of patients, thereby helping to uphold discriminatory social systems. What, then, are the roles and responsibilities of health professionals and their institutions? Some organisations, such as the American Psychiatric Association and the British Medical Association, have affirmed their opposition to discrimination and medical education is being used to change professional attitudes towards lesbian, gay, bisexual, and transgender people.5 The increasing demands of these consumers for appropriate health services have resulted in innovative programmes that might provide models for services elsewhere.4 Furthermore, research in mainstream health journals on concerns such as the effects of discrimination and violence based on sexual identity is growing and contributing to debate.4 Nevertheless, much work is still needed to place the health and human rights of lesbian, gay, bisexual, and transgender people on health agendas. Governments must act against discrimination through interventions with civil society, such as human-rights education with medical academic and training insti-

Measures that governments should take to prevent torture and ill-treatment based on sexual identity
1. Repeal laws that could result in the discrimination, prosecution, and punishment of people solely for their sexual orientation or gender identity. 2. Condemn torture and ill-treatment, whoever the victim, and give clear indications that this will not be tolerated. 3. Provide safeguards to protect lesbian, gay, bisexual, and transgender people from torture or ill-treatment in custody. 4. Prohibit forced medical treatment, including non-consensual treatments aimed at changing sexual orientation or gender identity. 5. Ensure that all allegations of torture and ill-treatment are investigated and those responsible brought to justice. 6. Protect lesbian, gay, bisexual, and transgender people, including children, against violence in the broader community, including domestic violence. 7. Protect refugees fleeing torture based on sexual identity. 8. Protect and support human-rights defenders at risk because of their work on issues of gender and sexual identity. 9. Strengthen international protection for lesbian, gay, bisexual, and transgender people through ratifying international human-rights instruments and ensuring that the human-rights issues of these groups are advanced by UN and regional human-rights agencies. 10. Combat discrimination through legal protection against homophobic abuses, initiate antidiscrimination campaigns, and ensure that lesbian, gay, bisexual and transgender organisations and individuals have freedom of association and assembly.
Adapted from reference 2.

THE LANCET Vol 358 December 1, 2001


For personal use. Only reproduce with permission from The Lancet Publishing Group.


tutions, organisations of health professionals, the criminal-justice system, and individual health-care providers (panel). Efforts by human-rights organisations and lesbian, gay, bisexual, and transgender people worldwide are leading to more powerful demands for access to rights within health care. Health-care providers and organisations of health professionals have a moral and professional responsibility to work in supporting measures to uphold rights and promote the health of this group. As the AI report notes, If we tolerate the denial of rights to any group, we undermine the whole

protective framework of human rights by taking away its central plankthe equal rights and dignity of all human beings.2
We thank Ria Boerema, Tom Emerson, Jeanelle de Gruchy, Alice M Miller, Cynthia Rothschild, Ignacio Saiz, and Jim Welsh for their thoughtful comments on earlier versions of this paper. 1 Amnesty International. Egypt: release child imprisoned for alleged sexual orientation. London: Amnesty International, 2001. (Available at Amnesty International. Crimes of hate, conspiracy of silencetorture and illtreatment based on sexual identity. London: Amnesty International, 2001. (Available at

Altman D. HIV, homophobia and human rights. Health Human Rights 1997; 2: 1522. Meyer IH. Why lesbian, gay, bisexual, and transgender public health? Am J Public Health 2001; 91: 85659. American Psychiatric Association. Gay, lesbian and bisexual issues [fact sheet].( nbisexualissues22701.pdf [accessed March 1, 2001]).

Simon Lewin, Ilan H Meyer

Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; and Columbia University, Mailman School of Public Health, Division of Sociomedical Sciences, New York, NY, USA (e-mail:

Rising tensions: Sharia law in Nigeria

comes as little surprise, therefore, recent increase in the number of that support for Sharia law is wideSharia punishments handed out spread among Nigerias Muslim comby courts in the northern states of munities. With an ineffectual secular Nigeria has caused outrage and congovernment struggling with issues of demnation from both national and corruption, poverty, and violenceso international human-rights groups. the argument goesperhaps a code Although the number of documented of justice based on Gods law will be human-rights abuses has lessened more up to the task. Nigeria is a secusince Nigerias return to civilian rule lar state, but the government allows in 1999 after 16 years of repressive for application of Sharia law for condictatorships, the recent extension of senting Muslims. Islamic Sharia law for criminal Although northern governments offences may have set the countrys have offered assurances that the human-rights record back many application of Sharia law will be years. restricted to Muslims, minority And there is much to be concerned Christian groups living in the area about. Only this month an Islamic remain unconvinced. Furthermore, court in Gwadabawa, Sokoto State, says Bronwen Manby of Human in northern Nigeria ruled that a pregRights Watch, many Muslims are nant woman be sentenced to death by also expressing reservations about stoning. The court had found Safiya Hussaini Tungar-Tudu guilty of having premarital sex, a punishable offence under Sharia law. Rights were not granted to Recent reports indicate that the include this image in sentence may now be delayed until electronic media. Please refer after she delivers the baby. A teenage girl was given 100 lashes in to the printed journal. January for a similar offence, even though her appeal was still pending at the time. Earlier this year, a 16-year-old boy from Kebbi State was found guilty of stealing money and sentenced to having his hand amputated. Human-rights groups say that all these cases flout international law. Such religious issues, as with everything in Nigeria, are complex. Life for most people is a desperate and constant struggle, more so perhaps in the predominantly Muslim northern regions that are often seen as worse off than the Christian south. Resources are scarce, poverty is rife, and the area bears witness to some of Africas worst health-care statistics. It Mosque damaged in anti-Sharia riots, Kaduna

the way Sharia is being implemented in Nigeria. There are serious concerns with the use of vigilante squads who administer instant punishments, Manby told The Lancet, and with the appointment of new Sharia tribunals headed by very inadequately trained judges with poor respect for due process when they hear cases. Such issues seek only to fuel preexisting religious and ethnic tensions in the northern regions, an area that has long been the focus of widespread violence. It is estimated that more than 6000 people have been killed in predominantly Muslim-Christian clashes throughout the country since 1999. 2000 people died in clashes in Kaduna last year, and reports from Bauchi state tell of hundreds killed and thousands displaced when Christians rioted in protest against imposed Islamic law. Many of the displaced are yet to return home, and remain reliant on the Red Cross for food and shelter. Adding yet more fuel to the fire, Nigerian Islamic leaders have warned against possible repercussions within Nigeria as a result of Americas so-called war against terrorism. Yet according to Cathy Huser of Mdecins Sans Frontires, a group that has been based in Nigeria since 1996, the international community must not ignore the fact that such violence is rooted in politics and economics. Essentially these outbursts of violence in Nigeria are all to do with controlling land and resources, in the face of extreme poverty and human misery; although religious and ethnic sparks often fuel the conflict, says Huser. In Nigeria, a cumulative effect of frustrations and


THE LANCET Vol 358 December 1, 2001

For personal use. Only reproduce with permission from The Lancet Publishing Group.