Despite tremendous progress toward acceptance and equality in Western society, the LGBT+ community suffers from significant health inequities perpetuated by ongoing homophobia and transphobia in the health-care system.
It is well documented that widespread barriers to health-care access continue to exist for LGBT+ people, resulting in negative health outcomes across this population. In North America alone, there are more than 20 million LGBT+ people (which is likely an underestimate); it is clear that ongoing health inequity for simply existing is not acceptable. Immediate and systemic action is required to address and mitigate these issues.
LGBT+ history: A brief overview
Homosexuality has existed throughout history and traverses all cultural lines and geography. It is important to mention this, as LGBT+ people around the world continue to be persecuted by egregious human rights violations.
Awareness of both the historical and current contexts of this population is vital for a greater understanding of the health inequities that persist. In Canada, homosexuality was illegal until 1969 and was branded as a mental illness until 1973. In earlier years, even on North American soil, members of the LGBT+ community were tortured, institutionalized, subject to barbaric medical experiments and treated as pariahs with the common belief that they could be “cured”. This attitude transcended time, with practices such as “conversion therapy” still being carried out today in Canada despite the human rights and legal progress the LGBT+ community has made.
During the HIV/AIDS crisis, LGBT+ people were stigmatized and attacked. The whole community was seen as a “plague” and basic dignity was stripped from them, even as they died alone in hospitals. This history lives within every LGBT+ person today, with many in the community continuing to face discrimination when attempting to access even the most basic care.
This history lives within every LGBT+ person today, with many still facing discrimination when attempting to access the most basic care.
The current state and LGBT+ health experience
In Canada, the LGBT+ population “experiences numerous health inequities” such as poor mental and physical health outcomes, decreased access to treatment (including HIV pre-exposure prophylaxis or PrEP ), higher rates of substance misuse and higher rates of chronic illness. LGBT+ people are also four times more likely to have suicidal thoughts compared to the general population.
There are many reasons for these inequities, including “social, legal and identity-related (such as age or ethnocultural background)” , social determinants of health relating to “oppression and discrimination” and overall intersectionality, which depicts how people often face multiple facets of oppression simultaneously (i.e., racism, homophobia and classism).
LGBT+ communities remain subject to “negative and humiliating experiences” while interacting with the health-care system. A history of oppression, maltreatment and stigma has resulted in LGBT+ people often staying silent with their health-care providers for fear of discrimination. Because it might not be outwardly apparent that someone is LGBT+, this population must constantly evaluate if it’s safe to “come out”. In fact, many LGBT+ people are often questioned by health-care providers in a heteronormative way, communication that assumes people are heterosexual (i.e., asking if a woman has a boyfriend or husband without considering that she could be a lesbian). This assumptive communication can cause stress and insecurity and further contributes to health disparities. There are numerous examples of this, but the following is poignant and powerful:
“…a woman told me about the time she went to a lab for some blood work. She presents feminine, but she hasn’t received her new ID yet. When she handed in her requisition and ID to the receptionist, she politely asked if the technician could please use her new female name when she was called. When the technician bellowed out her old male name, she froze. The technician called the name again and she was immobilized. Then the receptionist stood up, pointed to her and said loudly, “That’s him.”…she just sat there crying…until she finally found the strength to run out of the lab without getting her blood work done.”
Instances such as this erase the very identities of LGBT+ people and exacerbate the “otherness” and isolation that is felt. Assumptions and negative language, especially in a health-care setting that is supposed to be safe, can cause irreparable harm. Particularly in Canada, with progressive legislation and protection that should serve to prohibit discrimination in health-care settings, there is no place for these ongoing biases.
A way forward: How policy and leadership can improve LGBT+ health equity
Public health policy that is evidence-based, focused on health equity, actionable and inclusive will serve to address the inequities faced by LGBT+ people in the health-care system. Additionally, government, education and health system leadership is essential for advancing robust LGBT+ public health policy.
Currently, there are no official governmental frameworks (nationally or provincially) to guide best practice with respect to LGBT+ clients. There are certainly piecemeal efforts in various jurisdictions, but a central, government-mandated comprehensive population health approach would be an effective driver of equity. For example, the House of Commons Report of the Standing Committee on Health lists 23 recommendations that the Government of Canada could enact to improve the health of LGBT+ people. These recommendations touch on main themes of education, training, consultation, data collection, research and program funding and targeted policy revision specific to LGBT+ communities. Further, by explicitly including LGBT+ persons and health needs within Canada’s Public Health Goals, tangible population health strategies could be realized.
A large gap also exists within the education systems of health-care professionals in Canada. Overall curriculum requirements for comprehensive training on the unique needs of LGBT+ people do not exist. It is evident that the introduction of LGBT+-specific training better equips practitioners with the skills needed to treat this population; in turn, this would serve to create inclusive health-care environments. Both educational institutions and regulatory bodies have the power to address these gaps. There are resources available, such as the ARC Foundation’s Sexual Orientation Gender Identity (SOGI) education that could be tailored to health-care and embedded into medical curricula.
Beyond the medical education system, provincial ministries of health and regional health authorities (RHAs) play a pivotal role in addressing LGBT+ health inequities. There are a variety of best practice guidelines available that could be implemented. Further, RHAs could introduce ongoing training for staff to expand cultural competence in the LGBT+ realm. There are several partner organizations, such as the LGBT Foundation, that have developed materials such as Pride in Practice to provide safe care for LGBT+ people. These public institutions have the ability and resources to mandate guidelines into practice that are clearly needed to advance LGBT+ health improvements and create a culture of accountability for care providers.
Creating inclusive environments for LGBT+ clients is not difficult, yet it has not occurred on a broad scale in Canada or elsewhere. This lack of action is unacceptable, and the onus is on the health-care system and its leaders, from the local level to the federal government, to address LGBT+ health inequity. Understanding LGBT+ history, unique care needs and the “health and well-being inequities experienced from a structural perspective” is vital moving forward. Leadership at all levels is required to facilitate change. The lives of millions of people depend on it.