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Promoting LGBT health and wellbeing through inclusive policy development

11 pages
In this paper we argue the importance of including gender and sexually diverse populations in policy development towards a more inclusive form of health promotion. We emphasize the need to address the broad health and wellbeing issues and needs of LGBT people, rather than exclusively using an illness-based focus such as HIV/AIDS. We critically examine the limitations of population health, the social determinants of health (SDOH), and public health goals, in light of the lack of recognition of gender and sexually diverse individuals and communities. By first acknowledging the unique health and social care needs of LGBT people, then employing anti-oppressive, critical and intersectional analyses we offer recommendations for how to make population health perspectives, public health goals, and the design of public health promotion policy more inclusive of gender and sexual diversity. In health promotion research and practice, representation matters. It matters which populations are being targeted for health promotion interventions and for what purposes, and it matters which populations are being overlooked. In Canada, current health promotion policy is informed by population health and social determinants of health (SDOH) perspectives, as demonstrated by Public Health Goals for Canada. With Canada's multicultural makeup comes the challenge of ensuring that diverse populations are equitably and effectively recognized in public health and health promotion policy.
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International Journal for Equity in
BioMed CentralHealth
Open AccessResearch
Promoting LGBT health and wellbeing through inclusive policy
1 2 3 4Nick J Mulé* , Lori E Ross* , Barry Deeprose* , Beth E Jackson* ,
1 5 6Andrea Daley* , Anna Travers and Dick Moore
1 2Address: School of Social Work, York University, Toronto, Canada, Social Equity & Health Research Section, Centre for Addiction and Mental
3Health (CAMH), Department of Psychiatry, University of Toronto, Toronto, Canada, Ottawa LHIN Representative, Rainbow Health Ontario,
4 5Ottawa, Canada, Coordinator, Social Determinants of Health Stream, Ontario Rainbow Health Partnership Project, Toronto, Canada, Rainbow
6Health Ontario, Sherbourne Health Centre, Toronto, Canada and Seniors Program, 519 Church Street Community Centre, Toronto, Canada
Email: Nick J Mulé* - nickmule@yorku.ca; Lori E Ross* - l.ross@utoronto.ca; Barry Deeprose* - deeprose@cyberus.ca;
Beth E Jackson* - bethjackson@sympatico.ca; Andrea Daley* - adaley@yorku.ca; Anna Travers - atravers@rainbowhealthontario.ca;
Dick Moore - senior@the519.org
* Corresponding authors
Published: 15 May 2009 Received: 4 November 2008
Accepted: 15 May 2009
International Journal for Equity in Health 2009, 8:18 doi:10.1186/1475-9276-8-18
This article is available from: http://www.equityhealthj.com/content/8/1/18
© 2009 Mulé et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
In this paper we argue the importance of including gender and sexually diverse populations in policy
development towards a more inclusive form of health promotion. We emphasize the need to
address the broad health and wellbeing issues and needs of LGBT people, rather than exclusively
using an illness-based focus such as HIV/AIDS. We critically examine the limitations of population
health, the social determinants of health (SDOH), and public health goals, in light of the lack of
recognition of gender and sexually diverse individuals and communities. By first acknowledging the
unique health and social care needs of LGBT people, then employing anti-oppressive, critical and
intersectional analyses we offer recommendations for how to make population health perspectives,
public health goals, and the design of public health promotion policy more inclusive of gender and
sexual diversity. In health promotion research and practice, representation matters. It matters
which populations are being targeted for health promotion interventions and for what purposes,
and it matters which populations are being overlooked. In Canada, current health promotion policy
is informed by population health and social determinants of health (SDOH) perspectives, as
demonstrated by Public Health Goals for Canada. With Canada's multicultural makeup comes the
challenge of ensuring that diverse populations are equitably and effectively recognized in public
health and health promotion policy.
marginalized because of their gender identity and/or sex-Introduction
In this discursive paper we examine the extent of recogni- ual orientation; herein the term 'gender and sexually
tion of gender and sexually diverse populations (LGBTs) diverse populations' is used to address the collective iden-
(The phrase 'gender and sexually diverse populations' and tity of these populations, while 'LGBTs' is used to address
the acronym 'LGBT' both describe the lesbian, gay, bisex- the individuals that make up these communities) in
ual, transsexual, transgender, two-spirit, intersex, queer Canadian public health promotion policy. We review
and questioning individuals and communities who are LGBT health and wellbeing issues, examine limitations of
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existing models such as population health, the SDOH, inals), but have not included sexual minorities [7,8]. Two
and public health goals, in light of the lack of recognition latter reports included lesbians and bisexual women [9]
of gender and sexually diverse individuals and communi- and gay men [10,11]. Yet in the Canadian blueprint report
ties, and provide a critical analysis of the implications of Building on Values: The Future of Health Care in Canada [12]
health disparities. We argue that the gender and sexually LGBT populations are completely neglected in the dis-
diverse populations must be explicitly included in policy course on diversity where other minority groups are
development for a more inclusive form of health promo- addressed (including aging Canadians, those dwelling in
tion. In contrast to an illness-based focus such as HIV/ rural communities, those of lower socio-economic status,
AIDS, we emphasize the broad and unique health and ethnic groups, culturally diverse groups, men and women,
wellbeing needs of LGBT people employing anti-oppres- visible minorities, people with disabilities, and new Cana-
sive, critical and intersectional analyses. Although litera- dians).
ture has been drawn from the most part from Canadian
sources to address the realities of LBGT Canadians, we The Canadian Institute for Advanced Research (CIAR) and
also include literature from Australia, the UK and USA, members of its Population Health Program were highly
societies in which the socio-political-cultural experiences influential in the emergence of the population health
of gender and sexually diverse populations are similar approach in Canada. This perspective considers "proc-
albeit not identical. We then conclude with recommenda- esses by which system-level variables influence the health
tions for a more inclusive approach to recognizing gender of populations" [13]. Health Canada went on to describe
and sexually diverse populations in Canadian public the approach as a means "to maintain and improve the
health promotion models. health of the entire population and to reduce inequalities
in health between population groups" [14]. Despite this,
Public Health Policy in Canada there continues to be a heavy emphasis on targeting the
Historically, Canada has been at the forefront in public 'entire population' with regard to maintaining and
health. This was demonstrated by the contributions of the improving health and less so on reducing "inequalities in
Lalonde Report [1], which introduced the concept of health between population groups" [14]. Critics charge
'health promotion', and the Epp Report [2] which further that the population health approach has been narrowly
expanded Lalonde's concepts and developed the 'popula- focused on individualized characteristics and processes as
tion health' approach. In the Lalonde Report [1], health measured by large-scale surveys (i.e. National Population
determinants comprised four 'health fields' which Health Survey, Canadian Community Health Survey).
included biology, lifestyles, environments and health This approach has tended to position 'risk factors' only as
care. However, the report was ultimately understood to correlates to individualized attributes and behaviours,
champion 'lifestyle' interventions focusing on individual consequently holding to account affected/diseased indi-
rational action and responsibility, while downplaying the viduals [13,15]. Meanwhile qualitative, community-
impact of social structures on health [3]. Although the based research methods and findings are paid very little
Epp Report [2] and the WHO Ottawa Charter for Health attention. Because population health as an approach is
Promotion [4] shifted the focus toward 'healthy public not addressing social/structural determinants, it provides
policy', which acknowledged structural determinants of weak direction on solutions and social change. Popula-
health, community health promotion strategies since that tion health policies are devoid of guiding values that call
time have continued to target individual responsibility for for participation, community development or rectifying
health behaviours (witness HIV/AIDS prevention pro- social injustices [13]. The implications of this are detri-
grams). Thus, a micro level (individualized) lifestyle mental to those seeking the implementation of health
approach continues to dominate and define Canadian equities and policy change (i.e. the gender and sexually
health promotion [5] by targeting 'high risk' populations diverse among other populations) [3,13].
through large scale campaigns in which interventions pro-
mote risk reduction through behaviour change [6]. There- Sexual and Gender Diversity Issues in Canadian Public
fore, illness and behaviour remain central while sexuality Health Policy
and gender identity as social locations in the broader Simultaneous to the development of the public health
social health structures simply do not register. models, the Canadian LGBT communities amassed into a
social movement. Human rights protections based on sex-
Populations marginalized by gender identity and sexual ual orientation were fought for, and won, at the national,
orientation have, for the most part, been excluded from provincial and territorial legislative levels across Canada.
mainstream health promotion research, policy and prac- For example, activists have achieved the use of inclusive
tice. Documents submitted to the federal government language such as 'same-sex partner', accommodations for
have attempted to design models that capture targeted same-sex relationships, almost all the rights and responsi-
populations (e.g. age, sex, socio-economic status, Aborig- bilities of opposite-sex common-law relationships and
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the legalizing of same-sex marriage [16,17]. Although the either of the traditional genders). Such absence operates
resulting human rights protections are theoretically inclu- within the discipline and practice of social policy through
sive of 'services' such as health care, LGBTs for the most the ideology of heterosexuality, in which normative exist-
part, have not been recognized as an identifiable popula- ence and reproduction is based upon traditional hetero-
tion within the health care sector [18]. Further, gender sexual ideals [25-27].
identity is absent from most human rights legislation
across Canada with the exception of the Northwest Terri- This ideology of heterosexuality is manifest in social pol-
tories and the City of Toronto [19]. icy as an institutionalized system that normalizes and nat-
uralizes heterosexuality, and that informs structures of
A further element in the exclusion of LGBT issues from everyday life through, for example, marriage, reproduc-
Canadian public health policy is research methodology. tion and parenting. The ideology of heterosexuality is pro-
The health and wellbeing issues of gender and sexually moted by non-specificity, or rather a 'not naming' within
diverse Canadians, have for the most part, been identified social policy that appears to include all, but that in fact,
and taken up from a community-based perspective – gen- excludes the lives of gender and sexually diverse [28,29]
erated by participatory action research initiatives in which people. In Canada, the ideology of heterosexuality and
the LGBT communities were directly involved in the the phenomenon of non-specificity have been challenged
design, methodology, analysis and iteration of the find- by LGBT activists, who have argued against an assumed
ings. In other words, gender and sexually diverse commu- heterosexual citizen underlying public policy. However,
nities defined for themselves their health and wellbeing with the exception of demands for the recognition of
issues, needs and concerns [20]. In contrast, Health Can- MSM and associated health needs related to HIV/AIDS the
ada's epidemiological approach relies heavily on aggre- institution of heterosexuality continues to be systemati-
gated individual-level survey data, resulting in a cally reinforced and perpetuated in Canada's health policy
standardization of individualized attributes and experi- development and implementation (i.e. health promotion
ences in the health care system. This fails to consider and programs) that overlook LGBT populations. Public policy
analyze social relations and social forces' impact on developed in this climate of homo-negativity [30-32]
health [13,15]. Measurement of individual-level data implicitly normalizes and naturalizes heterosexuality
only, ultimately leads to a focus on individual-level inter- [33], resulting in a circular process and continued invisi-
ventions, overlooking the structural sources of health bility of the needs of gender and sexually diverse people.
Health Effects of Discrimination on Gender Identity and
Sexual OrientationIt is not surprising, then, that LGBT health needs are not
captured within this epidemiological, individualized and The strength and vibrancy of today's gender and sexually
illness-based approach. An outcome of this limited diverse communities is a testament to the movement's
approach is a disease-based focus (e.g. HIV/AIDS), that long and hard-fought battles for inclusion, recognition,
primarily focuses on treating rather than addressing vul- equality, equity and ultimately, acceptance in Canadian
nerabilities leading to unsafe sexual practices targeting society [34,35]. The continuing growth and development
certain epidemiological populations – for example men of the movement reflects the resilience required to with-
who have sex with men (MSM), erasing the social context stand the prejudice, discrimination, and stigma that are
of identities, and rendering invisible self-affirming gay still inflicted upon these communities. Both individually
and bisexual men in the process [21-24] (not to mention and systemically, the health effects of discrimination com-
lesbians, bisexual women, the trans and intersex popula- promise the wellbeing of the gender and sexually diverse
tions). populations [36].
The absence of Canadian gender and sexually diverse pop- It is beyond the scope of this paper to provide a compre-
ulations from the population health approach and hensive review of the health, health care and wellbeing
extended models (SDOH) and goals (e.g. Canada's Public issues of gender and sexually diverse individuals and com-
Health Goals 2005) demonstrates the insidiousness of munities. Jackson et al. [3] have drawn from available
heterosexism (a belief that heterosexuality is the norm review articles and selected non-governmental organiza-
and/or superior to all other forms of sexuality, whereas tion and government project reports to summarize key
other sexualities may be considered abnormal, unnatural findings relevant to gender and sexually diverse popula-
or not considered at all) and cis genderism (cis gender tions in Canada. Taken together, these sources indicate
refers to a traditional binary perspective on gender that that there are patterns of health and illness specific to
assigns strict gender roles to males and females without LGBT people that are independent or may be a result of
acknowledgment of overlapping gender characteristics, the marginalization and discrimination they experience.
transitioning between genders or not identifying with These include health issues that are more common among
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gay men (e.g. certain cancers, alcohol and tobacco use, The framework in Figure 1 illustrates, from a structural
sexually transmitted infections) [20,37], lesbians (e.g. cer- perspective, the health and wellbeing inequities experi-
vical and ovarian cancers, alcohol and tobacco use, repro- enced by gender and sexually diverse populations. From
ductive health issues) [20,37], bisexuals(e.g. STD/I the outset, at the top of the framework, social justice issues
concerns, and particular barriers to accessing health care are framed within an intersectional discourse acknowl-
due to lack of knowledge on the part of health providers) edging the multiple social locations and power relation-
[20,37,38] transgender, transsexual (e.g. lack of access to ships that LGBT individuals and communities inhabit.
hormone therapies and publicly funded surgery for gen- These varying social locations intersect with one's gender
der transition, certain cancers related to hormone replace- identity and/or sexuality, and the resulting effects on
ment therapies, complications from steroid use, health and wellbeing. The next two boxes respectively out-
complications from surgical interventions, refusal of care line internalized and externalized forms of oppression.
for routine health issues) [37,39], and intersex people The former lists affected individualized responses; the lat-
(lack of education and training of health professionals, ter lists both individually targeted and systemic forms of
non-consensual sex assignment, cis gender pressures, discrimination with stigmatizing effects. The interaction
stigma, and withholding of information) [40]. of individual acts and/or systemic discrimination in the
latter has a direct impact on the health and wellbeing of
The Ministerial Advisory Committee on Gay and Lesbian the individual in the former. Further down the frame-
Health [41] for the State of Victoria, Australia reports on work, specified vulnerabilities and susceptibilities are out-
the health effects for LGBT populations of heterosexism, lined on individual and systemic levels, indicating
sexism, and transphobia. The outcomes of these social repercussions on health and wellbeing for these popula-
patterns of discrimination include: violence and persist- tions. The box at the bottom of the framework provides
ent threats of violence, discrimination, social marginaliza- the known health disparities for gender and sexually
tion, social invisibility, isolation, self-denial, guilt, and diverse populations. The determinants of health are
internalized homo/bi/transphobia. These patterns have located at the centre of the framework, midstream
been noted to produce negative health effects such as between that which ails and the resulting impacts. This
increased rates of alcohol and drug use, greater risks for framework illustrates the down streaming structural
sexually transmitted infections, and high rates of depres- effects that health and wellness inequities have on gender
sion and suicide [3]. LGBT peoples' abilities to form and and sexually diverse populations, shifting the focus from
sustain supportive relationships can be negatively individualized pathology to systemic oppression.
impacted by persistent discrimination in the realms of
Interactions of the SDOH with Discrimination against friends and social networks, finding supportive spiritual/
faith communities, as well as intimate relationships and Gender and Sexually Diverse Populations
parenting [41]. Given the health inequities experienced by gender and
sexually diverse populations, it is important to explore
Gender and sexually diverse populations experience how the SDOH recognized in Canadian public health pol-
reduced access to quality health care and under-utilization icy affect these populations. Health Canada and the Pub-
of health care services as a result of fear or lack of confi- lic Health Agency of Canada name 12 social determinants
dence, due to widespread and persistent individual and that impact on health (see middle box labeled 'Social
systemic discrimination against them [10,20,37,41-45]. Determinants of Health' in Figure 1), all of which interact
Jackson et al. [3] note that negative/prejudiced attitudes with gender identity and sexual orientation. The following
on the part of health care providers combined with sys- examples demonstrate these intersections:
temic discrimination leave gender and sexually diverse
patients subject to bias, discrimination, and substandard Income and social status are key determinants of health for
care. Formats of medical history-taking (such as intake many LGBT people, as their educational achievement and
and other medical forms) are frequently exclusive of gen- career opportunities can be affected by the prejudice and
der and sexually diverse experiences which may discour- phobic reactions they experience at school, in the work-
age the disclosure of gender identity, sexual orientation, place, or elsewhere [44,45]. Studies in the US have refuted
and health-related behaviour or circumstances. Conse- the market-created myth regarding 'gay affluence' [46,47].
quently, LGBT people may avoid or delay care (e.g. screen- The economic situation for Canadian gay men and lesbi-
ing for various health conditions) and/or remain silent ans is complex with the former having personal income
about important health concerns. Thus, health problems 12 percent lower and the latter 15 percent higher than
may be undiagnosed, misdiagnosed, and/or left untreated their similarly situated heterosexual counterparts (though
until they are more severe and less amenable to treatment both lesbians and heterosexual women, on average, earn
[43]. Compounding these problems is the limited knowl- less than either heterosexual or gay men). Bisexual men
edge on the part of health care providers about the gender and women earn 30 and 15 percent less than heterosexual
and sexually diverse population's health issues [3]. individuals, respectively, suggesting that bisexual identity
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Social Justice Issues
Outside and Inside LGBT Populations
Homophobia (Social and Legal) Transphobia Cis Genderism
Racism Heterosexism Misogyny
Colonialism Sexism
Internalization in Individual
Externalization: Societal Discrimination (Marginalization/Stigmatization)
Individual Acts Systemic DiscriminationSocial isolation/alienation
Violence Heterosexism: assumption of heterosexuality and/or Social invisibility /Lack of role models
privileging of heterosexuality Low Self-Esteem
Prejudice Ignorance of LGBT sexuality and society Poverty/Underemployment
Bullying (esp. in schools) Invisibility of LGBT people and issuesClosetry/self-denial
Shunning Devaluing/negating LGBT culture & relationships Disenfranchisement/powerlessness
Peer, parental, sibling Ignorance of LGBT health issues Hypervigilence/over-achieving
rejection Barriers to access Dropping out of school/low attainment
Verbal abuse Social Exclusion Underemployment/diminished careers
Humiliating Erasure from research Homelessness/street involvement
Disdaining/denigrating Bias in health care providers Guilt/shame
Harassment/ Ridicule Nonpublic health infrastructure for LGBT people Fear/pervasive personal insecurity
Hostile environments Lack of LGBT community resources Spiritual deprivation
Inner turmoil and psychic pain
Determinants of Health
Income & Social Status Social Support Networks Employment Gender
Social Environments Biology & Genetic Endowment Physical Environments Culture
Healthy child development Personal Health Practices & Coping Skills Health Services Education
Conditions that affirm positive choices for coming out (proposed for LGBT population)
Lack of appropriate medical/social services Obstacles to accessing health and social services
Chronic anxiety/stress Invisibility in/exclusion from health promotion
Suicide ideation and attempts prevention initiatives
Social Isolation and lack of community Depression/despair
Addictive behaviors (alcohol, party and injection drugs, sex, tobacco) Sexual risk taking
Eating disorders Delayed seeking ofhealth care and treatment
Mental Healthproblems
Outcomes (Disparities in Health)
Cost of Social Exclusion: 5,500 premature deaths in Canada and $8B in costs annually
(Banks 2003)
Increased suicide rates: at least 3Xin LGBT youth, 14X in gay men
Higher smoking rates: 50% for gay men and 100% for lesbians
Increasing rates of HIV in gay men/youth
Higher rate of depression—3 to 5 times greater than in heterosexuals
Higher rates of violence: 70% LGBT have been verbally abused and 25% have been physically abused
Higher rates of alcohol abuse: estimated 30% of LGBT adults have problem with alcohol
Higher rates of STI in gay men and transpeople
Higher rates of unmet health care needs (21.8%) compared to heterosexuals (12.7%) in LGBT people
Higher rates of Hepatitis A & B in gay men/youth
Increased anal cancer in gay men: 80X more common in gay and bisexual men
Higher levels of obesity in lesbians
Higher levels of eating disorders in gay men
Higher rates of homelessness and street involvement in LGBT youth
Higher rates of sexual abuse in LGBT youth
Figure 1Structural Framework for Gender and Sexually Diverse Health and Wellbeing Inequities
Structural Framework for Gender and Sexually Diverse Health and Wellbeing Inequities.
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in particular may be associated with socioeconomic dep- sumed to be asexual, may fear coming out to care provid-
rivation [48]. Poverty is particularly common among peo- ers, and may face access barriers in participating in the
ple living with HIV/AIDS due to restrictive income- gender and sexually diverse communities and finding
support programs and costly medical therapies [49]. Sim- appropriate sensitive health care services for their needs
ilarly, trans populations experience extreme social and [43].
economic marginalization, not to mention costs of hor-
mone and gender reassignment interventions A lack of adequate social support networks negatively affects
[37,41,44,45]. Finally, gender and sexually diverse youth LGBT people generally and more particularly based on
who flee or are expelled from abusive homes and who are age. Youth struggle with limited funds, fear of rejection,
fearing and/or experiencing rejection have high rates of concerns about confidentiality and isolation [37,43]. On
homelessness [44,45,50]. Moreover, a disproportionate the other hand, seniors encounter ageism both within and
number of street involved youth identify as sexual minor- outside gender and sexually diverse communities, are
ities [51,52]. made to feel invisible and desexualized, fear prejudice and
phobias in institutional care, and may have lived through
Gender as a social determinant of health has different a history in which gender and sexual diversity was pathol-
effects on girls and boys, women and men [53,54]. Much ogized [43,58]. Indeed, many of the first generation of lib-
of this is the result of sexism, such that prejudice and pho- erated gay men and lesbians feel coerced to return to the
bias directed at gender and sexually diverse people con- closet in their declining years.
tributes to maintaining a binary system of gender and
sexist social relations [45]. Lesbians and bisexual women Increasingly, members of the gender and sexually diverse
are doubly affected by inequality [38,41] on the basis of communities are questioning the SDOH and the extent to
gender and sexual orientation, and 'gender identity' has which LGBT concerns are recognized therein [3]. Firstly,
not been given adequate, if any, consideration as a deter- these populations are not explicitly represented as an
minant of health in Canadian health policy, further mar- identity group. The social determinants of culture and
ginalizing transsexual, transgender, and intersex people. gender, which were added to Health Canada materials in
the late 1990s, could theoretically capture the gender and
'Culture' as a health determinant is intended to capture sexually diverse populations, but a diversified analysis has
experiences of racism and colonialism, yet little research not been adequately taken up in either area. Although
exists on how these intersect with marginalization due to increased health risks for some groups "determined by
gender identity and/or sexual orientation. Racial and eth- dominant cultural values that contribute to the perpetua-
nic minority individuals who are also LGBT experience tion of conditions such as marginalization, stigmatization
compounded challenges in accessing and utilizing health ..." [59] have been described as determinants of health
services [43,45]. Two-Spirit people and First Nations, related to culture, Aboriginal and immigrant populations
Inuit and Métis people who identify as gender and/or sex- are featured, whereas gender and sexually diverse popula-
ually diverse have been reported to face serious inner con- tions are neither mentioned within these featured popula-
flicts with identity, acceptance, and access to health tions nor discussed independently. Gender focuses on
services [43,55]. social determinants that affect the health of those that fit
traditional binary notions of socially constructed females
Physical and social environments can determine the health and males. The effects of gender on health have not
and wellbeing of LGBT people based upon whether they included experiences of transsexual, transgender and
dwell in rural and remote areas or suburban or major intersex people. Therefore, despite the health effects of
urban centres. Those living in rural and remote communi- prejudice and discrimination on LGBT populations and
ties are reported to experience higher rates of heterosexism the impact of intersections with and among other deter-
and related phobias [43] and fewer adequate services [56]. minants of health, these populations are ignored in con-
However, some research suggests that rural gender and ventional population health models. As a result, they are
sexually diverse communities may compensate by having overlooked when developing health policy – we explore
stronger relations with family and friends, a higher stand- this concern in the next section on Canada's Public Health
ard of living and less stress compared to gender and sexu- Goals.
ally diverse people living in urban centres [57].
Applying Canada's Public Health Goals to Gender and
Sexually Diverse PopulationsThe biology and genetic endowment of gender and sexually
diverse people living with a (dis)ability interacts with the In October, 2005, the Public Health Agency of Canada
prejudice and discrimination they face. They may be pre- announced a new set of Public Health Goals for Canada.
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Its intent was to provide a series of guideposts for health this would need to be undertaken both formally and
improvement and to enhance Canadians' quality of life, informally at all levels of the education system and in all
and as such was not intended to provide a detailed means public health promotion.
of achieving this. The goals consist of the overarching goal
that "As a nation, we aspire to a Canada in which every The goal that we all "participate in and influence the
person is as healthy as they can be – physically, mentally, decisions that affect our personal and collective health
emotionally, and spiritually" and nine additional goals and well-being" [60] highlights the importance of com-
that are sub-sectioned under four categories [60]. Below, munity involvement in not only one's own health and
we provide examples for ensuring that the nine Public health care, but that of others. Like other population
Health Goals for Canada address the concerns of gender groups, it is imperative that gender and sexually diverse
and sexually diverse people: people be directly involved in the planning, design, devel-
opment, and implementation of research, programs and
? Addressing the goal of enabling our children and youth, services, and health care and social service delivery
particularly those that identify as gender and/or sexually [39,62]. Direct investment is necessary to achieve this
diverse or are members of same-sex families, to "reach goal.
their full potential, growing up happy, healthy, confident
and secure" [60] could be supported by initiatives to for- The goal of making the world "a healthy place for all
malize referral networks, support services, mentoring pro- people, through leadership, collaboration and knowl-
grams, and inclusive education on diversity edge" [60] requires improved knowledge production and
[38,39,43,61]. This would require the systemic participa- exchange in the forms of research and information dis-
tion of the health care, social service and education sectors semination regarding gender and sexually diverse people's
that work with children and youth. health and well-being. Capacity building strategies should
encourage collaborative partnerships between members
? The goal of ensuring that our social and physical envi- of the gender and sexually diverse communities, activists,
ronments are safe and healthy could be supported by frontline service providers, and other professionals, policy
establishing government-sponsored, public health cam- makers and academics to work together towards creating
paigns against heterosexism, sexism, cis genderism and effective educational and prevention-focused health pro-
various phobias, within and across the health care, social motion initiatives [38,39,43,61,62].
service, housing, and employment sectors [43]. This
would merely uphold human rights legislation at both Ensuring the goal that every person gets "the support
federal and provincial/territorial levels in Canada that at and information they need to make healthy choices" [60]
minimum recognizes sexual orientation, if not gender requires gender and sexually diverse-specific health pro-
identity. motion programs. These should provide education and
information resources about healthy sexuality and gender
? Regarding the goal of ensuring that "every person has variations, and other health issues of relevance to these
dignity, a sense of belonging, and contributes to support- populations [38,39,43,61]. Additionally, health promo-
ive families, friendships and diverse communities" [60] tion strategies that are aimed at the general public address-
supportive services (e.g. 'help phone lines', community ing prejudice, heterosexism and various phobias towards
outreach/development initiatives, positive websites and the gender and sexually diverse will go a long way in
other electronic methods of networking, trans-positive reducing health disparities.
shelters, and transitional housing), could be provided for
gender and sexually diverse individuals and their families, The commitment to "prevent and respond to health and
while ensuring that existing barriers to services and bene- safety threats via Canadian and globally coordinated
fits are removed [38,39,43,61]. This would require the rec- efforts", represents one of the greatest gaps for the gender
ognition of the gender and sexually diverse in the and sexually diverse populations. Within Canada, a sys-
development and implementation of both policies and temic connection needs to be made between human
services. rights protections for the gender and sexually diverse pop-
ulations and corresponding health and social services
? "Life-long learning" could be achieved through continu- [43]. Canada would then be in a better position to pro-
ing education of the general public and of health care and mote the inclusion of gender and sexually diverse individ-
social service providers regarding gender and sexually uals and communities at the global level.
diverse issues, together with integrated and targeted pro-
grams for LGBT individuals and communities (e.g. The last goal calling for a strong health system that
employment resources such as skills training for trans "responds to disparities in health status and offers timely,
people) [38,39,43,61]. For a comprehensive approach, appropriate care" [60] requires initiatives that create sen-
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sitive, equitable and accessible services for gender and sex- (micro) [63]. The anti-oppression approach arose from
ually diverse people. This would include but not be social justice movements (inclusive of the queer move-
limited to a systemic recognition of discrimination based ment) that have challenged hegemonic social structures
on gender identity and sexual orientation as important and norms and emphasized the intersectional realities of
determinants of health, intake forms that are inclusive diverse populations [3,64] with a goal of achieving social
and representative, services that are sensitive to the unique justice. Institutions with power at the macro level will
stressors that LGBT people experience (e.g. increased often use such social identities to oppress leaving individ-
attention to the existence of LGBT couples and families, uals at the micro level, few if any supports [65,66] (for
improved access to hormone therapy, psychosocial sup- example, in services for women that do not take into con-
port and sex/gender reassignment surgeries), and sideration race, class, sexual orientation, or gender iden-
improved anti-oppressive curricula at post-secondary tity, among others). Recognition of these dilemmas and
institutions training future health and social service pro- how they affect LGBT populations and their social identi-
fessionals [38,39,43,61,62]. Ideally, an interconnected ties and health and wellbeing requires us to reframe pop-
dialogue needs to be developed and maintained between ulation health, the SDOH, and public health goals to
stakeholders at all levels in order to continuously respond provide a stronger foundation for inclusive health promo-
to the ever-changing health needs of these populations. tion policies and initiatives that capture gender and sexual
These examples provide a valuable beginning for under-
standing, conceptualizing and developing a discourse of Figure 2 illustrates a critical analysis of gender and sexual
public health that captures objectives, indicators, targets diversity health and wellbeing in three phases, as a means
and strategies that are inclusive of LGBT individuals and of expanding current discourse on public health promo-
communities. The links between the health and wellbeing tion to be inclusive of these populations, and applying
issues of gender and sexually diverse populations and such discourse to the development of LGBT-positive
Canada's new Public Health Goals offer a blueprint of the health promotion policy. Each phase is displayed on a
kind of initiatives and activities that must take place in progressive continuum indicating impact or process
order to ensure the overarching goal, that "every person is required to address this population's health and wellbe-
as healthy as they can be – physically, mentally, emotion- ing issues. In the first phase, an analysis is provided that
ally, and spiritually" [60]. outlines the negative impact of phobias and heterosexism
on the health and wellbeing of LGBT people with com-
Discussion: towards an inclusive approach promised health and wellbeing outcomes. In other words,
In this paper, we have illustrated how Canada's new experiencing homo/bi/transphobia, heterosexism, and/or
Health Goals can connect to the health and wellbeing cis genderism negatively affects the health and wellbeing
issues affecting gender and sexually diverse people. Such of these communities' members. The second phase
connections now need to be acknowledged and applied in acknowledges the diversity of LGBT populations and how
the development and implementation of public health multiple oppressions compound negative health effects
policy. To date, Canada (along with parts of the UK and and compromise health and wellbeing outcomes.
the USA) has failed to capture gender and sexually diverse Although the focus of this paper necessitates the placing
populations in health and social service public policies of an analysis of phobias, heterosexism and cis genderism
[18], despite evidence for numerous structurally-driven, in the first phase, diverse members of LGBT communities
population-based health disparities [3]. LGBT people are may perceive/experience/prioritize the effects of oppres-
generally not captured in the Canadian lexicon of 'visible sion based on multiple identities differently.
minorities' [23]. This exclusion is at great cost: lack of rec-
ognition of gender and sexually diverse populations by The third and final phase of figure 2 provides a progressive
the health care system has been estimated to result in continuum by which health and wellbeing disparities
close to 5,500 premature deaths in Canada and $8B in experienced by gender and sexually diverse populations
annual costs [42]. can be addressed. This continuum begins with interven-
tions to challenge and expand public health promotion
LGBT people cross all socio-economic, ethno-racial, age, discourse to reflect these populations. There must be rec-
gender, (dis)ability, religious, geographical location, edu- ognition of the unique and specific health and wellbeing
cational, and relationship status lines. Consequently, for issues affecting LGBT people, substantiated with knowl-
many in these communities, their existence is made up of edge guided by a critical/structural analysis as outlined in
multiple intersecting social identities. These identities the previous two phases. Beyond informing discourse, the
intersect and are affected by societal power dynamics that next two elements of the framework address implementa-
can result in oppressions and/or privileges that play out tion, in which LGBT individuals and communities be rep-
structurally (macro) or individually and interpersonally resented in policy, funding, programming, and services,
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Analysis of Gender and Sexually Diverse Health and Wellbeing Disparities:
GenderandSexuallyDiverse-Based NegativeImpact Compromised
Phobias&Heterosexism Health &Wellbeing
Compounding Intersectional Impacts:
Diversity-Based Inequities
Colonialism Negative Impact Compromised
Racism Health&Wellbeing
Other Oppressions
Addressing Gender and Sexually Diverse Health and Wellbeing Disparities:
Means Agents Transformative Practice Health &Wellness
Recognition Gender andSexuallyDiverse Inclusive
Knowledge Communities Accessible
Representation Health Care&Social Service Sensitive
Prioritization Systems Equitable
Broader Society
Gender anFigure 2 d Sexual Diversity Health and Wellbeing Critical Analysis
Gender and Sexual Diversity Health and Wellbeing Critical Analysis.
prioritizing them in order to address their health and well- discourse in order to be inclusive of the gender and sexu-
being concerns. For this to succeed three agents must ally diverse populations. We have highlighted a series of
mobilize these issues: first and foremost, the gender and health and wellbeing inequities and disparities unique to
sexually diverse communities' voices and experiences these populations, providing a structural framework that
must define the issues and set the context; second, health illustrates the downstream effects. The SDOH, population
care and social service systems must reshape how they health perspective and the public health goals of Canada
provide service delivery; and third, it is important that were critically examined as current models of public
broader society become knowledgeable and sensitized to health promotion, revealing shortcomings and limita-
these issues via public health education campaigns in tions that in effect exclude LGBT people and communi-
order to combat phobias, heterosexism and cis genderism ties. This is not to say that the current models cannot be
directed at these populations. Associated agents such as modified to be inclusive of the gender and sexually
policy makers, funders and postsecondary educational diverse, as was illustrated via the expanded public health
institutions, and professional associations that train goals posited. By employing anti-oppressive, critical, and
health care and social service professionals would also intersectional analyses to examine, deconstruct and chal-
need to contribute to this process. An engagement and lenge these models, a more expansive and inclusive dis-
commitment to the process of addressing these concerns course emerges that makes room for and can
on the part of these agents would contribute to a trans- accommodate populations currently excluded. We have
formative practice in which service provision would also offered an upstream analysis that proposes a method
become more inclusive, accessible, sensitive, and equita- of understanding health and wellbeing disparities experi-
ble towards the gender and sexually diverse with a positive enced by LGBT populations, the compound health effects
health and wellness outcome. of intersecting oppressions and a systemic means of
addressing them. Thus, we argue that an expansion of
Conclusion public health promotion discourse that would recognize
In this paper we have described a series of perspectives, gender and sexually diverse populations, together with a
ideas, and concepts to expand public health promotion reframing of the SDOH, population health, and Canada's
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Prevention in the Context of our Health and Wellness Ottawa: Canadianprocess as part of the SDOH stream of the Ontario Rain-
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ada's Primary Health Care Transition Fund, the support of the Canadian Wellbeing, Toronto 2007.
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