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Opinion
Curriculum content disorder: Indian Medical Education and the saga of NMC’s guidelines for CBME curriculum
The National Medical Commission’s (NMC) revised Competency Based Medical Education (CBME) has caused quite a stir in the medical community and rightly so
Let’s take a look
Let’s take a look(Pic: EdexLive Desk)
Dr L Ramakrishnan
Published on:
16 Sep 2024, 7:30 am
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Last week, mainstream and social media are abuzz with news of errors of omission and commission in the undergraduate medical curriculum published by India’s National Medical Commission (NMC) in August 2024.

Concerns have been raised about the presence of outdated and inaccurate content pertaining to gender and sexuality, and the absence of disability-related competencies that were part of the previous (2019) version.

The dismay and exasperation of medical educators and the communities most affected by these regressive steps may be best understood by reviewing progress in medical and legal understanding over the past few decades.

Sexual orientations other than heterosexual (in which men are only attracted to women and vice versa), and gender identities other than cisgender (in which an individual’s gender identity is perfectly aligned with the societal expectations considered appropriate to their sex assigned at birth), were historically treated as mental disorders in medicine and criminalized in law.

Let’s go back to history

In 1973, homosexuality was removed from the Diagnostic and Statistical Manual of Mental Disorders, and in 1990, from the World Health Organization’s (WHO) International Classification of Diseases (ICD). More recently, the ICD-11 adopted by the 72nd World Health Assembly in 2019, removed the diagnosis “gender identity disorder” for transgender persons, with recognition that gender incongruence is not a disorder but a natural variation in how people experience their gender.

Individuals departing from the cisgender heterosexual norm were criminalised under sodomy laws originating in England and inherited by all its colonies, including India.

The struggle to read down Section 377 of the Indian Penal Code and decriminalise sexual acts of consenting adults was finally won in the Supreme Court in 2018.

Indian medical curricula and textbooks, even those published after WHO’s revision in 1990, have continued to reflect the dual colonial legacies of pathologization and criminalization. The terms sodomy (referring to anal sex) and buccal coitus (oral sex) fail to distinguish between consensual and non-consensual acts, and have remained a sexual offense in forensic medicine texts and in both the 2019 and 2024 ‘pre-furore’ revision of NMC’s curriculum.

KS Narayana Reddy’s venerable The Essentials of Forensic Medicine & Toxicology, even its most recent (2022, 35th) edition refers to lesbians as mental degenerates and nymphomaniacs who are prone to homicide and suicide.

Sunesh Kumar and co-editors’ (2023, 18th) Indian edition of Shaw’s Textbook of Gynecology, faithfully reproduces outdated content that “homosexuality, transvestism and transsexuality are abnormal sexual behaviors”, blithely ignoring evidence from WHO and statements from professional medical associations such as the Indian Psychiatric Society.

In 2019, medical educators, students and activists were quick to note that the newly released Competency-Based Medical Education Curriculum (CBME) contained many of the same problematic content in subjects such as psychiatry and forensic medicine, and lacked any science-based and medico-legal updates pertaining to sexual orientation and gender identity.

Letters were written to the Medical Council of India (MCI, subsequently National Medical Commission) pointing out these errors.

Such medically unsound content in curricula and textbooks has also reinforced societal homophobia and transphobia, and supported medical practices that violate the Hippocratic dictum “First Do No Harm”. Conversion practices — both unscientific and unethical — that aim to change lesbian, gay and bisexual persons to heterosexual and transgender persons to cisgender have been pervasive in India, with many parents approaching medical and mental health practitioners seeking to change the sexual orientation, gender identity or expression of their children.

The harmful psychological consequences of such conversion practices can last a lifetime.

In 2021, a lesbian couple who had run away from their homophobic natal families in Madurai, sought protection from the Madras High Court. Justice Anand Venkatesh, in landmark interim orders in this case Sushma and anr. Versus Commission of Police and others, Tamil Nadu addressed several issues facing the LGBTQIA+ community based on his consultations with a queer-affirmative counselor and discussions with members of the LGBTQIA+ communities and organizations.

Among the orders issued were directions to the NMC to purge erroneous and outdated content pertaining to LGBTQIA+ persons in the competency-based curriculum, and ban conversion practices.

Responding to the interim orders, the NMC notified the state medical councils in 2022 that conversion “therapy” would be considered professional misconduct. It also commissioned experts to rewrite the curricula of psychiatry and forensic medicine. These were submitted to the Madras High Court.

Here comes the curriculum

The positive changes brought about by the NMC in their response to the Madras High Court were greeted with elation by medical educators and LGBTQIA+ communities.

However, the relief was short-lived: NMC — in a curious instance of institutional amnesia — brought out a 2024 CBME curriculum that largely mirrored the 2019 content, with no inclusion of the modified content submitted to Madras High Court in 2022.

The only exception was the addition of a competency PS9.2 Demonstrate knowledge of medico-legal, societal, ethical and humanitarian principles on dealing with LGBTQA+ community in Psychiatry. Ironically, the competency was listed under Topic 9: Psychosexual and Gender Identity Disorders, suggesting a copy-paste job that did not even bother to remove the obsolete categorisation of transgender persons as having a disorder.

Following country-wide protests from community members and collectives, healthcare professions and professional organisations such as Doctors with Disabilities: Agents for Change and Association for Transgender Health in India, NMC hastily withdrew the curriculum. It has since re-issued a further revised curriculum, in which errors in the forensic medicine section have been rectified and the notion of informed consent introduced.

However, the psychiatry curriculum continues to feature “gender identity disorder”.

Issues of diversity in sexual orientation and gender identity remain conspicuously absent from sections such as adolescence in pediatrics. Moreover, the disability-related competencies that were included in the 2019 version are no longer present.

The path forward

The NMC needs to reflect on its haste to bring out ill-thought out curricula, and engage with medical and mental health professionals and community members to revise all relevant topics and bring out a queer-, trans- and disability-inclusive curriculum.

Medico-legal aspects need to be updated with the relevant content from Supreme Court judgements (NALSA 2014, Navtej 2018, Supriyo 2023) and Acts around Rights of Transgender Persons, Mental Health and Persons with Disabilities.

Along with removal of outdated and inaccurate content, topics reflecting medically current knowledge on homosexuality, bisexuality, gender incongruence and dysphoria need to be included in all relevant subjects such as pediatrics, psychiatry, and gynaecology.

Global best practice recommendations in pediatrics around eliminating non-essential surgeries for infants born with atypical genitalia, also the subject of a 2019 Madras High Court order, need to be included.

Competencies around clinical history-taking need to include approaches that elicit information on gender, sexual orientation and behavior in a non-judgmental manner.

For instance, assumptions that all clients seeking gynecological services are heterosexual cis women need to be dropped. As recommended by Dr Satendra Singh in his representation to the Ministries of Health and Social Justice, the updated content, rather than being restricted to a foundation course, needs to be integrated longitudinally with the Attitude, Ethics and Communication (AETCOM) component of medical education.

Finally, all these changes need to also be reflected in the textbooks, teaching and evaluation, and to be updated regularly to reflect progress in our medical understanding of human diversity.

(L Ramakrishnan is associated with Solidarity and Action Against The HIV Infection in India (SAATHII), a public health NGO headquartered in Chennai. Views are personal.)

MedicalLGBTQIA+NMCguidelinesCBME
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