1Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden, 2Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden and 3Erasmus University Rotterdam, Rotterdam, the Netherlands1Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden, 2Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden and 3Erasmus University Rotterdam, Rotterdam, the Netherlands
Arjan van der Star
1Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden, 2Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden and 3Erasmus University Rotterdam, Rotterdam, the Netherlands
After attending an excellent and well-organized 5th European Public Health Conference with the main theme All inclusive Public Health, it felt appropriate to reflect on what factors are considered when talking about inclusion and exclusion regarding health concerns. During the last day of the conference, we heard some inspiring presentations highlighting the importance of awareness of inequalities based on being small, few or different and the responsibility to manage public health policies to overcome inequality in Europe’s health based on ethnic or social background.
Health disparities can be described as differences in incidence, prevalence, mortality, disease burden or other measure of adverse health between minority and majority population groups.1 Awareness of health disparities in specific populations, in particular based on ethnical background, has increased during the past decades. Research on psychosocial factors such as discrimination, context and cultural views of health, which influence health disparities, has begun to increase our understanding of the mechanisms behind such inequalities.1 In addition to ethnicity, disparities based on many other factors such as gender, age, socioeconomic status, geography and disability have been identified. During the past several years, public health policy and research have begun to address the issues of lesbian, gay, bisexual and transgender (LGBT) populations,2 and many official public health agencies call for programmes addressing the specific needs of LGBT individuals. But is attention to LGBT populations of interest for public health research and policy makers, and should it be included as part of public health goals?
LGBT populations are diverse and the level of specific public health concerns is most likely just as diverse. LGBT populations vary on all kinds of sociodemographic factors, e.g. ethnic, cultural, educational, income and education, as well as the degree to which their sexuality or gender identity is important to their self-definition. In some ways, similarities between LGBT and non-LGBT people might be greater than the similarities between individuals in various LGBT communities. However, despite many differences, LGBT individuals have similar experiences regarding stigma, discrimination, rejection and threat of violence, no matter where they live or what culture they belong to.3–5 However, the level of acceptance for minority sexual orientations differs greatly by country. In the European Social Survey 2010, a question was used to assess level of acceptance of gay men and lesbians. The proportion of respondents who agreed to a statement that ‘Gay men and lesbians should be free to live their own life as they wish’ varied greatly between countries, from around 90% in the Netherlands, Sweden and Norway to about one-third of the respondents in Russia and Ukraine, see figure 1. These results indicate that in many countries, LGBT people still live in communities where a majority of the population supports discrimination and inequality for sexual minorities. In many countries, LGBT people are also subject to legal discrimination concerning basic civil rights, e.g. regarding recognition of same-sex unions. Studies also show that transgender individuals are regularly stigmatized and discriminated against both in the health care sector and in the society as a whole.8 The International Lesbian, Gay, Bisexual, Trans and Intersex Association in Europe collected information regarding laws and administrative practices that protect or violate the human rights of LGBT people in the European countries, and used this information to construct an index for comparisons between countries,7 see figure 1. Although there is a connection between laws and administrative practices and level of LGBT acceptance, it is noteworthy that some countries with a relatively good score on acceptance have a poor ranking on the International Lesbian, Gay, Bisexual, Trans and Intersex Association in Europe’s index. This could indicate that the development of acceptance of LGBT individuals in the general population, and changes in laws and administration, develop thought separate but related processes.
Percentage agreeing to the statement ‘Gay men and lesbians should be free to live their own life as they wish’ in different countries (data from the European Social Survey round 5 in 20106) and the International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA) European Rainbow index reflecting European countries’ laws and administrative practices that protect or violate the human rights of LGBT people.7
Traditionally, LGBT public health research has almost exclusively focused on sexually transmitted diseases. In particular, the start of the HIV/AIDS epidemic in the 1980s brought visibility to the LGBT population as a group with specific health needs. However, the public health consequences of discrimination of LGBT individuals have only recently been focus of greater attention. Current research, although still limited, points to a higher prevalence of certain conditions among LGBT people that call for the attention of public health researchers and professionals.2 The most significant area of concern is the increased prevalence of mental health disorders. Recent studies from both North America and Europe show that LGBT youth are at greater risk for suicide attempts than non-LGBT youth and have higher prevalence of depression and anxiety diagnoses.3 Some studies have also found higher rates of certain health-related behaviours such as tobacco use in sexual minority groups, higher rates of unsafe sexual practices among gay men, higher risk of drug use among male-to-female transgender individuals and higher rates of heavy alcohol use and obesity among lesbians.9 Furthermore, there is a concern that some LGBT populations have an increased risk of specific cancers owing to reluctance to participate in screening programmes (e.g. breast and cervical screening among lesbian women) and unique exposures to risk (e.g. anal human papilloma virus in gay men).9,10 These findings show a need for clinicians and public health professionals to develop programmes that specialize in the care and public health needs of LGBT populations.
In the spirit of the European Public Health Conference on All inclusive Public Health, greater efforts are needed to reduce health disparities among LGBT populations in the future, but also more knowledge through improved data quality and well-designed studies is needed. Health status surveys should include information regarding sexual orientation and gender identities, and culturally appropriate interventions should be developed to improve disparities regarding specific health issues relevant for the LGBT population, such as mental health, smoking, alcohol use, cancer prevention activities and sexually transmitted infections. As more knowledge is gathered regarding health disparities, efficient ways to assess these disparities and the specific needs of sexual and gender minority populations, public health researchers and professionals will be better suited to work toward a truly all inclusive public health.
Conflicts of interest: None declared.
Greater efforts are needed to reduce health disparities among LGBT populations.
More knowledge about the public health situation of LGBT populations through improved data quality and well-designed studies is needed.
Appropriate interventions should be developed regarding specific health issues relevant for the LGBT population, such as mental health, smoking, alcohol use, cancer prevention activities and sexually transmitted infections.
Committee on Lesbian G, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities; Board on the Health of Select Populations; Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: The National Academies Press, 2011.