Ruth McNair, University of Melbourne: Consequences of Sexual Orientation and Gender Identity Diversity


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Ruth McNair, Director, General Practice and Primary Health Care Node, NW Academic Centre, Department of General Practice, The University of Melbourne delivered this presentation at the 2013 Social Determinants of Health conference. The conference brought together health, social services and public policy organisations to discuss how social determinants affect the health of the nation and to consider how policy decisions can be targeted to reduce health inequities. The agenda facilitated much needed discussion on new approaches to manage social determinants of health and bridge the gap in health between the socially disadvantaged and the broader Australian population. For more information about the event, please visit the conference website:

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Ruth McNair, University of Melbourne: Consequences of Sexual Orientation and Gender Identity Diversity

  1. 1. Health inequalities related to diverse sexual and gender identities, and social inclusion responses Social Determinants of Health Conference Assoc Prof Ruth McNair, December 2013
  2. 2. Outline A range of health inequalities amongst LGBTQ people Social determinants of LGBTQ health Evidence of social exclusion Social inclusion responses • Social connectedness • Coalition building • Social citizenship
  3. 3. Defining the sub-groups L lesbian same sex attracted G gay B bisexual T questioning mainly heterosexual transgender queer
  4. 4. Sexual Orientation: definitions Sexual Desire or Attraction • attracted to same sex only, to both sexes or to opposite only Population based proportions Sex in Australia study, Aust. NZ J of Public Health 2003 Women n= 9,578 12.8% Men n= 9,728 6.8% • WSW, MSM exclusively, or with women and men, or only with opposite sex 8.5% 6.0% Sexual Identity Lesb 0.8% Gay 1.6% • self-identify as lesbian or gay, bisexual, heterosexual • prefer to avoid labels Bi Bi 0.9% Sexual Behaviour 1.4% Unsure 0.1% 0.1%
  5. 5. Health inequalities – compared with heterosexual peers •Mental health – Higher levels depression, anxiety, suicidal thoughts, higher self harm •Substance use – Higher levels of use – alcohol, tobacco, illicit drugs – Longer periods of use •Sexual health – Men – higher rates of sexually transmitted infections – Women – same rates but different pattern •Cancer risk factors – Lower screening rates e.g. Pap smears – Higher risk factors – obesity, smoking, alcohol, HPV •Body image – Men – increased use of body building drugs, HIV related effects – Women – possibly increased obesity – Bisexuals - eating disorders higher •Social support – Lower family of origin support, workplace support, community support
  6. 6. Mental health disparities – 12 month Lifetime Feeling Queer and Blue- Literature review for beyondblue 2008 Private Lives, 2006 80% women, 70% men had experienced depression during their lifetime
  7. 7. Use of drugs –comparing same sex attracted young women (YW), SSAY men (YM) and heterosexual young people: Marijuana, heroin, party drugs, injected drugs (Hillier et al 1998) 70 60 50 40 YW YM Yhets 30 20 10 0 Mar Her PD ID
  8. 8. Further inequalities for bisexual people Compared with LG people, bisexual (and unsure, questioning, mainly heterosexual) people have higher rates of: • STI diagnosis and abnormal Pap test results • blood-borne virus infection • experiences of all forms of violence • suicidality • harmful drinking and drug use • disordered eating patterns • depression and anxiety
  9. 9. Mental health differences Australian Longitudinal Study of Women’s Health, cohort aged 25-30 (Hughes, Szalacha, McNair – 2010 Soc Sci Med) Exclusively Heterosexual Mainly Heterosexual Bisexual Lesbian X2 Statistic CES-D >10 24.5% 33.9% 44.4% 28.6% 44.2*** Depression diagnosis 11.2% 25.4% 34.0% 25.0% 151.7*** Anxiety disorder diag. 5.5% 10.9% 20.0% 14.6% 73.0*** Life not worth living 1 week 4.9% 14.0% 16.2% 9.2% 76.8*** Self harm 6/12 2.0% 8.0% 14.1% 4.1% 134.2***
  10. 10. Even greater inequalities for transgender/gender queer people • Ostracisation -‘Passing’ as the affirmed gender can be difficult • Financial hardship -~90% lose their job during gender affirmation • Isolation -many lose current relationship during transition • Depression, suicidality • Alcohol and drug use
  11. 11. Social determinants of LGBT health
  12. 12. Health determinants: VicHealth, 2006
  13. 13. Big picture determinants • Social connection good • Embraced health • Affirmed Resilience • Social isolation ill• Marginalised health • Discriminated against Minority Stress
  14. 14. Summary of social determinants Policy and legislative exclusion • Minority gender roles, identity • Marginalised • Negative social attitudes • Fear rejection Minority stress Health care services- limited ‘cultural access’ – acceptability and respect Trauma, violence • Family –rejection • Peer- bullying • School/workplace discrimination • Sexual violence • Physical violence • Lack of control over social environment • Lack of systemic response to marginal status Alcohol, smoking and illicit drug use Depression, Anxiety Suicidality, self harm • Also increases risk for trauma • Marginalisation • Drug and alcohol use
  15. 15. • Alcohol use amongst LBQ women linked to poor mental health and experiences of discrimination Older age • Homophobic abuse amongst young people linked to suicidality Gender Youth Selected evidence for links between LGBTQ minority stress and poor health • Loneliness amongst older LB people linked to minority stress
  16. 16. Abuse experiences of SS attracted youth Writing Themselves In 3 -2010 (Thanks to Lynne Hillier) 61% were verbally abused because of their sexuality (44% in 1998, 46% in 2004) 69% experienced other types of homophobia 18% were physically assaulted because of their sexuality (14% in 1998; 16% in 2004)
  17. 17. Direct relationship between abuse experiences and suicidality Writing Themselves In 3 -2010 100% Thought about self harm Harmed yourself Thought about suicide 80% Attempted suicide 60% 40% 20% 0% Never experienced abuse Experienced verbal abuse only Experienced physical abuse
  18. 18. Relationship between suicidality and social support Study in Oregon,USA of 31,852 Year 11 students (1,413 -4.4% lesbian, gay, and bisexual) Hatzenbuehler, 2011, Pediatrics • LGB youth were significantly more likely to attempt suicide in the previous 12 months, compared with heterosexuals (21.5% vs 4.2%). • Risk of LGB attempting suicide was 20% greater in unsupportive environments compared to supportive environments. • Supportive social environments were associated with fewer suicide attempts (controlling for depressive symptoms, binge drinking, peer victimization, and physical abuse by an adult)
  19. 19. Alcohol intake (AUDIT score), and % experiencing discrimination – ALICE study 2013 online survey 521 LBQ women, mean age 34 50 45 40 35 30 25 20 15 10 5 0 44.8 39.3 25.7 26.8 Discrimination yes Discrim effected alcohol intake
  20. 20. Loneliness amongst older LGB adults (Kuyper and Fokkemer, 2009 & 2010) Sample of 122 older LGB adults in the Netherlands: • More lonely than heterosexual elders related to – higher levels of divorce – less likely to have children or to have less contact with their children – less contact with other members of their families – less frequent churchgoers • Highest levels of loneliness related to minority stress – those who had experienced negative reactions to SO – those who expected those reactions • Less loneliness – having an LGB social network
  21. 21. Further evidence of social exclusion at systemic level Policy & Legislation Health & Social services • WHO Closing the Gap Report • Census • National suicide prevention policy • Mental health policy • Marriage • Neutral approach • Lack of LGBTI training • No/little funding for LGBT health beyond HIV • Experiences of discrimination Partial citizenship
  22. 22. Citizenship (Richardson, 2004) • Full citizenship as a heterosexual – Access to all public institutions – Equal rights to employment, education, health, relationship and family, safety and protection, freedom of speech and religion – Can live an open life – Participate in advice and decision-making • People of diverse identities traditionally assume a heteronormative stance = partial citizenship – Conceal – Assimilate to the norm – seek to be treated the same as everyone else (as if they are heterosexual)
  23. 23. Marriage “As long as marriage is open only to heterosexuals, and civil partnerships only to lesbians and gay men, the British government is maintaining a symbolic separation of straights and gays, and sending out the clear message that our relationships are of less value to society than heterosexual ones. This is insulting, demeaning, and profoundly discriminatory: an affront to social justice and human rights.” Sue Wilkinson and Celia Kitzinger, 2006
  24. 24. Partial citizenship creates 2 classes of LGBT people Seidman cited in Richardson, D. (2004). Locating Sexualities: From Here to Normality. Sexualities, 7(4), 391-411. 1. ‘The normal gay’: assimilation • is gender conventional • lives in a monogamous, long-term relationship • defends family values, while not having children • displays national pride 2. The ‘other’ LGBT: difference • gender subversive, androgynous, non-operative trans, intersex • lives with children • single • non-monogamous
  25. 25. ‘Modern heterosexism’ encourages assimilation Mardi Gras, Sydney 1978 and 2013 “still marching” The Age 3/3/13 – Assumption that being LGBT is the same as being heterosexual – That there is no longer any discrimination or prejudice – LGBT people are said to ‘exaggerate’ their difference – Therefore bring negative social attitudes on themselves
  26. 26. Heterosexism in healthcare - the neutral stance • A study of family physicians in Canada – How they approach patients with socio-cultural differences – ethnicity, race, socio-economic status, sexual orientation • Five main approaches to diversity: – – – – – maintaining that differences do not matter seeking to avoid discrimination accommodating socio-cultural differences seeking to better understand differences challenging inequities
  27. 27. The neutral stance – silences LGBT disclosure Healthcare providers rarely ask patients about their sexual orientation why: (Hinchliffe, 2005) assume heterosexuality poor knowledge not relevant concerned to ‘open Pandora’s box’ don’t know how to ask believe it is intrusive believe it is offensive
  28. 28. Equality in difference = substantive equality Move to recognising and celebrating difference. ‘Substantive equality’, which ‘is concerned, in addition [to formal equality], with…ensuring that laws, policies and practices do not maintain, but rather alleviate, the inherent disadvantage that particular groups experience’. UN Committee on Economic, Social and Cultural Rights (CESCR)
  29. 29. Social inclusion responses 1. Social connectedness 2. Coalition building 3. Social citizenship
  30. 30. Social connectedness Two strategies used by LGBT people that build resilience (Oswald, 2002): a) Intentionality Deliberate choice of supportive family/friends Deliberate choice of disclosure timing b) Redefinition Becoming political Re-defining family Integrating sexual minority identity into other identities
  31. 31. Coalition building • Safe Schools Coalition – Vic now National • Gay-straight alliances in schools • Industry partnerships – e.g. Pride@NAB, Police GL network, • Beyondblue – Queer Voices “The coalition of schools and supporters is dedicated to creating safer educational environments where same sex attracted and gender questioning young people are supported, every family can belong, every teacher can teach, and every student can learn.”
  32. 32. Social citizenship An Australian Parliamentary review of social inclusion policy advocated for social citizenship as an opportunity for community participation, rather than social inclusion, which implies passive involvement (Buckmaster & Thomas, 2009)
  33. 33. Recent examples of LGBT inclusion Legislation Health policy Data Collection
  34. 34. Federal Equality - 2008 The Federal Government amended 84 laws which discriminate against same-sex couples in – taxation – social security – employment – Medicare – veteran's affairs – superannuation – worker's compensation – family law
  35. 35. Further legislative and policy reforms • Youth suicide prevention policy • National women’s and men’s health policies 2010 • National LGBTI Ageing and Aged Care Strategy 2012 • Sex Discrimination Amendment (Sexual Orientation, Gender Identity and Intersex Status) 2013
  36. 36. Inclusion in national data sets • • • • Census – same sex cohabiting relationships National mental health survey – since 2007 National Household Drug survey since 2010 Australian Longitudinal Study of Women’s Health (2000, 2001, 2003) • Longitudinal Male health study (2013)
  37. 37. Conclusion – LGBT health relies on ongoing efforts to Reduce assimilation, silencing, marginalisation, discrimination Increase full citizenship, social connection, coalition and inclusion
  38. 38. Thank you Ruth McNair Department of General Practice, The University of Melbourne