The past two years have brought issues of health, wellbeing and access to healthcare into sharp relief, as we all have attempted to adjust as best we can to the many uncertainties of an unfolding global pandemic. In recent media and political discourses, the refrain of ‘we’re all in this together’ has rung loud, yet anyone involved in researching or delivering healthcare knows that access to healthcare is not equitable, even in non-pandemic times.
Historically, the relationship between LGBTQI+ people and healthcare has often been a tumultuous one; LGBTQI+ people seem to forever have to balance their need for a safe, adequate, and appropriate healthcare with the concurrent objection to being pathologised, treated as ill, or as being inherently at a risk of ill health. One of the realities we cannot avoid, however, is that many within our LGBTQI+ communities are indeed more likely to experience health inequalities and in many different forms.
Much focus in this area is given to issues of sexual health, in particular, the higher prevalence of sexually acquired infections and HIV amongst gay and bisexual men, as well as some Trans communities. This focus has led to some really effective and welcome specialist healthcare provision in this area, which other areas of healthcare could learn a lot from. However, concurrently, we can also see that this focus can sometimes lead to the engendering of stigmatising views around Gay, Bi and Trans Health. A recently evolving outbreak of a rare viral infection known as monkeypox amongst gay and bisexual men in the UK and across Europe has seen a particular focus on this disease exclusively being discussed in relation to gay and bisexual men, when in fact, anyone could be susceptible to infection; we have seen this too play out in discourse around HIV which not only stigmatises gay and bisexual men but also other people living with HIV and does little to encourage testing and treatment.
41 percent of LGBT QI+ people in Ireland are not open about their gender or sexual identity to any healthcare provider...
This is where the provision of specialist healthcare must tread carefully, so as not to stereotype or stigmatise those requiring it Indeed, we know that the stigmatisation of LGBTQI+ people is a prime factor in the experience of health disparities within our communities. Psychologist Ilan Meyer developed a theory of ‘minority stress’ throughout the 1990’s and 2000’s, which is now widely accepted as a major factor in why LGBTQI+ people experience disparities in health outcomes. The model examines how wider social exclusion of gender and sexual minorities leads to an internalised stigmatisation, high levels of stress, and impacts not only on health-seeking behaviours but also on many aspects of health inequality.
Minority stress is most widely considered when thinking about mental health outcomes for LGBTQI+ communities, however, there is a growing evidence-base that reveals how issues related to minority stress can also have negative impacts on many physical health outcomes. Researchers in the USA, led by Associate Professor Annesa Flentje, found that internalised stigma as experienced in minority stress can have negative impact upon one’s overall physical health, immune response, HIV specific outcomes, cardiovascular outcomes, metabolic outcomes, cancer related outcomes, and hormonal outcomes.
As someone who researches gender and sexual minority health, one thing that has become very apparent to me, is that while we as researchers are becoming aware of some of the specific health inequalities which impact LGBTQI+ people, there is a lot that we do not know. Many health and medical studies unfortunately still do not consider gender and sexual identity when analysing their findings; therefore, any disparities in the outcomes for LGBTQI+ people remain invisible. If you do not count us, we cannot count.
This issue of invisibility is an issue not only in research, but also in healthcare practice. The 2019 EU Fundamental Rights Agency survey of LGBTQI+ people found that 41 percent of LGBTQI+ people in Ireland are not open about their gender or sexual identity to any healthcare provider. The survey does not elaborate on the reasons as to why people choose not to come out, however, we do know from UK research conducted by Stonewall that many LGBTQI+ people fear ill-treatment in healthcare if they do come out. This is not to say that LGBTQI+ people should feel pressured to come out in situations where they are not comfortable doing so; instead, it is imperative that healthcare services provided to LGBTQI+ people should be safe spaces to come out. We also must be cognisant that some people may not wish to come out - some of the gay men in my own PhD research did not think that it was relevant to disclose their sexual identity in all healthcare encounters. However, I contend that it might be difficult for us to receive safe, adequate, and appropriate healthcare, if the people or services provided are not aware of core facets of our identity and of our lives.
Research I’m currently leading aims to engage with LGBTQI+ communities in Ireland to explore what our preferences are for healthcare delivery in Ireland, and in doing so, it aims to work with communities in developing community-led healthcare for LGBTQI+ people.