This controversial decision and the larger ongoing government crackdown on lesbian, gay, bisexual, and transgender LGBT communities in Tanzania have garnered the attention of public health officials and international journalists, who have expressed concerns about their health ramifications and associated human rights violations [ 2 — 4 ]. Time to act These three countries and the movements within them offer hope and tangible examples for how citizens, healthcare professionals, and allied organizations can stand together. It has been reported that Tanzanian physicians, under the direction of law enforcement, have subjected men accused of same-sex behavior to forced anal examination in order to determine their sexual orientation [ 4 , 5 ]. A malicious procedure is employed without medical indication or forensic justification. More recently, in Egypt, physicians have attempted to determine this through electromyography, sonography, and manometry of the anal sphincter, pelvic floor, and rectum, respectively [ 9 ]. Ethical ramifications Central to the practice of medicine is the Hippocratic Oath, to first do no harm. In clinical care, anal examinations are routinely preformed for specific indications and to answer carefully formulated diagnostic questions.
Individual providers asked to perform forced anal examinations should resist the practice whenever possible, even when they themselves are being coerced or intimidated to conduct these examinations. Due to the possibility of coercion, individual physicians may face challenges resisting requests to perform such procedures, although they are abusive, medically unindicated, and yield no helpful information. In October of , the Tanzanian government forced the closure of internationally supported HIV testing and treatment centers designed to serve key populations, including sex workers and men who have sex with men MSM [ 1 ]. Healthcare workers may face challenges in resisting state-sponsored medical ethics and human rights violations [ 17 , 18 ], particularly when states are using providers to achieve political ends and oppress a vulnerable population. Additionally, the panel described some of the negative consequences of the exams, including pain; trauma to the anus, anal canal, or rectum; humiliation; and shame [ 12 ]. This controversial decision and the larger ongoing government crackdown on lesbian, gay, bisexual, and transgender LGBT communities in Tanzania have garnered the attention of public health officials and international journalists, who have expressed concerns about their health ramifications and associated human rights violations [ 2 — 4 ]. The so-called research is often conducted on prisoners or detainees and confers harm with no potential for individual or societal benefit [ 9 ]. Summary points It has been reported that, in at least nine countries, forced anal examinations are used to investigate or punish alleged same-sex behavior between consenting men or transgender women. During examination, individuals may be stripped, compelled to assume humiliating positions, and examined in front of others, without consent or under coercion. Recognizing this, the WMA passed a resolution denouncing forced anal examinations to substantiate same-sex activity and called for an immediate stop to medically useless exams that are outside accepted standards of practice [ 16 ]. In Egypt and Tunisia, forensic medical specialists submit a report describing the results of the exam as evidence to be used in court, and similar procedures have been used in Cameroon, Zambia, and Lebanon. In , the Office of the United Nations High Commissioner for Human Rights recommended that forced anal examinations be banned worldwide [ 10 ]; subsequently, a joint UN statement was released denouncing the practice [ 11 ]. They should use their power and influence to more effectively oppose this practice and promote adherence to professional and ethical codes. Bad science and false evidence The earliest recorded tests purported to detect homosexuality were described by a 19th century French forensic doctor who erroneously claimed that six criteria could be used to identify homosexuality on examination [ 9 ]. It is likely that forced anal examinations produce a profile of psychiatric morbidity similar to rape or sexual harassment, both of which are associated with a heightened risk of suicidality and post-traumatic stress disorder [ 12 , 13 ]. In several countries, forced anal examinations are reported to have been performed by healthcare providers at the request of police or other security operatives and consist of procedures entirely distinct from any examination of the anus, anal canal, or rectum used in clinical care [ 6 ]. In Tunisia, the government banned the practice after physicians repeatedly refused to administer the exam and human rights groups advocated for policy change [ 5 , 19 ]. The statement discredited the most commonly cited reason for conducting exams—to determine anal sphincter tone. Scope of the problem and recent progress Over the past seven years, several countries have reportedly used the findings of forced anal examinations as official evidence in legal proceedings [ 6 ]. Healthcare providers, professional organizations, and normative agencies, including the World Health Organization, all have an important role to play in bringing about an end to this practice. It is time to unite in action and bring about an end to this egregious practice. In Uganda, Kenya, Tanzania, and Turkmenistan, exams may be used in conjunction with an investigation or conducted unofficially to harm or punish suspected individuals [ 6 ]. Over the past seven years, forced anal examinations have reportedly occurred in at least nine countries, without clinical indication, to aid in the prosecution of alleged same-sex behavior between consenting adult men or transgender women [ 5 , 6 ]. In these settings, forced anal examinations are usually performed by healthcare providers at the request of law enforcement officials, and are procedures entirely distinct from those used legitimately in clinical care. A malicious procedure is employed without medical indication or forensic justification. Little is known about the true prevalence of this practice, but the fact that it is codified in legal systems, used in multiple countries, and is the subject of both human rights and news reports suggests an immediate need for advocacy and intervention.
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