Health equity for the LGBT community

Author: Winnie Fu

February 2017

While healthcare may often be seen as a system generalizable across populations, it is important to recognize and understand intersectionality and diversity in North America and its implications towards healthcare. One of the prevalent social issues disrupting equitable health is the lack of support received by the lesbian, gay, bisexual and transgender community. It is difficult to validate population estimates of the LGBT community in North America (and globally) due to the tendency of individuals from this community to publicly identify with a heteronormative sexual orientation. Nonetheless, the LGBT community continues to be a significant yet often overlooked minority group.

Primarily, discrimination based on sexual orientation at home, in the workplace, or among peers as well as antigay violence can lead to a host of problems. Studies imply that LGBT patients have an increased risk of suicide, eating disorders, substance misuse, and breast and anal cancer. There is no reliable way to record orientations of persons who have committed suicide. However, a correlation between sexual orientation and suicidal behaviour have been observed worldwide. In particular, it is estimated that LGBT teens are 3 times more likely to attempt suicide than heterosexual adolescents. An early study estimated that about a third of the adult gay population suffered from substance abuse and one study demonstrated that almost 60% of bisexual and gay male youth met the criteria for substance abuse. Furthermore, gay men appear to exhibit higher rates of disordered eating (such as dieting or binge eating) than heterosexual men. Additionally, lesbians have lower rates of seeing family doctors and receiving breast examinations, thus increasing their risk of breast cancer. For persons engaging in anal intercourse, the risk of becoming developing high grade anal intraepithelial neoplasia and anal cancer increases. It is also worthwhile to note that transgender persons face greater difficulties within this community, with election of gender reassignment surgery being one of the contributors to the psychological and physical factors that may influence their overall wellbeing.

These health risks are largely influenced by several sources, some of which may be socioeconomically based. An Ontario study found that half of trans people were living on less than $15,000 a year. However, the heavy discrimination and stigmatization experienced by the LGBT community most significantly contributes to the elevated health risks. This can propagate serious implications that invalidates an equitable health model for LGBT individuals.

The underlying problem attributed to the health inequity experienced by the LGBT community is the lack of studies addressing sexual orientation. In particular, bisexual men and women are largely underrepresented in several research samples, accounting for less than 10% of respondents from a literature review analyzing a cohort of studies. Furthermore, health studies that do include the lesbian and gay population tend to sample from white, middle-class, average or above average income populations living in urban areas. This undermines the reliability and generalizability of such studies and highlights the need for intersectional discussions involving the LGBT community.

Another point of concern is the attitude and education of health care professionals concerning the LGBT community and the distinct issues they face. In a study conducted by Allen et al. among LGB adolescents (aged 18-23), it was found that two-thirds of the participants never discussed sexual orientation with their healthcare provider but reported a desire to do so. Furthermore, LGB persons have reported disrespectful behaviour or refusal of treatment by healthcare providers. Conversely, healthcare providers have reported insufficient training to care for LGB persons. A qualitative Canadian study of lesbians regarding their cancer diagnosis by Singling et al. found that a minority of participants were targeted, denied care, or had their social contexts relevant to their care dismissed and a majority of participants noticed a lack of psychosocial support in regards to the context of their sexual orientation. Lack of education on the part of the healthcare provider coupled with an obvious discomfort or lack of respect for patients may deter LGBT persons from visiting healthcare providers to receive proper care and information. Furthermore, the involuntary coupling of homosexuality and AIDS (initially known as gay-related immune deficiency) amongst healthcare providers seems to increase the levels of homophobia within the healthcare community. Inexperience regarding this subject may be due to the lack of education in medical schools across North America. A study in the US found that almost half of medical students exhibited explicit bias towards LGBT persons and the majority of medical students demonstrated implicit bias. In a study of 11 Canadian medical schools, Obedin-Malvier et al. found that on average, 4 hours of preclinical teaching was spent on LGBT health with no medical school incorporating a clinical component in their curriculum.

Equitable access to healthcare may be compromised in the face of heteronormative culture and is just one of the many ways that sexuality-based discrimination may manifest itself. Some effective ways to mitigate the two main issues discussed in this article, lack of studies on the LGBT community and lack of knowledge among health care providers, are to encourage researchers to conduct more representative studies on this particular population as well as to educate healthcare providers on the distinct issues experienced by this community. However, the problem of health inequity in this community is a dynamic one and can only begin to be resolved by using a comprehensive approach.

A health equity promotion model proposed by Fredriksen-Goldsen et al. theorizes a new framework from which solutions to LGBT health disparities may be discussed. The fundamental premise for this framework builds on the idea that all individuals have the right to good health and that it is the responsibility of the society to ensure the everybody’s potential is achieved. From this framework, the Health Equity Promotion Model is built on three tiers: the social, the environmental, and the individual. The social context in which LGBT communities are rooted highlights the differing sexual identities, race, age, socioeconomic status, disability status, and several other aspects that exist. The heterogeneity of this community disproves the notion that the solution to health inequity must be the same for all LGBT individuals. The environmental factors that influence health experience in this community includes the discrimination and victimization of this group, which varies with the settings LGBT individuals may find themselves in as well as the structural and institutional policies enforced (for example, legally recognizing marriage). It recognizes that individuals with similar life experiences may diverge in their

response: through a health-promoting response or an adverse response. These responses may be dictated by the behavioral, social, psychological, and biological makeup of each individual.

While general public discourse denouncing discrimination and stigmatization of LGBT persons is ongoing, it is important to recognize and address the specific issues that have surfaced as a result of the prejudice endured by the LGBT community. Health inequity continues to be one of the prevalent issues facing this community and quick-fix solutions are not a permanent option. The diversity within the LGBT community proves the evolving problems experienced by different individuals and underlines the need for an inclusive approach towards this issue. Health inequity in the LGBT community is a side effect of a larger problem steeped in stigma and ignorance. By approaching health inequity directly while taking into account the factors that have facilitated this problem, change may also be imparted within a social context.

References:

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Queen's IHI