Since the groundbreaking 2011 UN resolution called for attention to the violence and discrimination committed against individuals because of their sexual orientation and gender identity, the visibility of LGBTQI populations has increased globally. There is mounting evidence of LGBTQI health inequities driven by stigma, discrimination, and violence. In December, 2020, 70 UN member states had criminal laws targeting sexual or gender minorities—two with de facto criminalisation and 68 with specific criminal provisions against same-sex sexual practices, six of which prescribe punishment with the death penalty. Despite recognition of these structural and social determinants of health, insufficient progress has been made in actions to address them.
Many aspects of LGBTQI health and their determinants are woefully understudied. Key priorities for advancing LGBTQI health research include filling gaps in knowledge by region, health condition, sexual orientation and gender identity group, theoretical frameworks, and methods. Importantly, researchers must collect and use data to advance the wellbeing of LGBTQI individuals, communities, and populations (panel). Simply identifying disparities by sexual orientation, gender identity, or intersex status is not enough and could exacerbate stigma against LGBTQI people in some settings. Researchers must also frame health disparities within the sociopolitical conditions that create them, clearly document the connection between these conditions and LGBTQI health, and conduct analyses that can lead to effective interventions.
Panel
Recommendations for filling gaps in LGBTQI health research
Populations and topics
• It is important that data analyses disaggregate participants by sexual orientation and gender identity rather than assume results apply across broad LGBTQI categories.
• Research is needed that disentangles identity, attraction, and practices, as well as sex and gender identity from gender attribution.
• Lesbian health outside of North America is understudied, particularly on topics other than breast cancer and obesity. There is a need for research on lesbian sexual health, including sexual function, HIV, and safer sex. COVID-19 impacts are underexamined with lesbian and bisexual women.
• Gay men's health needs to be examined beyond HIV, with a life course perspective.
• Transgender health issues should be examined beyond HIV, gender-affirming surgery and mental health problems.
• The health of intersex people should be studied beyond the impacts of surgical and hormonal treatments to focus on holistic health.
• Sexual pleasure is important to examine as a component of sexual health and rights among sexual and gender minority people.
• Strengths-based research frameworks are needed, particularly those that examine solidarity, social cohesion, and connectedness, and health benefits of social movement building. Individual and collective resilience must also be examined to document and promote the strengths of LGBTQI communities.
• Intervention research is needed that addresses systemic and structural issues, as well as community-led intervention research informed by community priorities.
• Research on structural factors is required, including power structures, health impacts of criminalisation, legal protections, and social norms and attitudes.
• There are knowledge gaps of the health impacts of incarceration and alternatives to incarceration among LGBTQI people.
• Increased research is needed on non-communicable diseases with LGBTQI populations.
• More research is needed on health-care provider perceptions, attitudes, and knowledge toward LGBTQI clients, including effective strategies to improve provider care across diverse geographical contexts.
• Behaviour change research has focused almost exclusively on reducing health risk behaviours of LGBTQI individuals. Studies are needed that examine ways to promote behaviour change among policy makers and other people in power—eg, how to turn adversaries into advocates.
Frameworks and methods
• Methods can use population-based data, including adding sexual orientation and gender identity measures to demographic and health surveys and other national surveys, and ensuring privacy, confidentiality, and protection.
• Approaches can advance dialogue on research ethics board considerations for conducting research with (rather than on) LGBTQI people, with critical reflection on how LGBTQI people are often framed as inherently vulnerable.
• Longitudinal cohort data are needed across global contexts, especially data on older LGBTQI people.
• Methods can be developed that honour diverse identities and accurately measure sexual orientation and gender identity, avoiding analytic microaggressions.
• Intersectional approaches to LGBTQI health research should take into account the variance between and within high-income, low-income, and middle-income contexts and move beyond the minority stress model to explicitly incorporate the role of power structures in determining health outcomes.
• Inclusive studies should aim to have LGBTQI sample sizes large enough for robust analysis.
• Qualitative studies can be developed to better understand nuances, experiences, processes, and the “why” behind LGBTQI health inequities, alongside documenting experiences of health-enabling environments.
Most data on LGBTQI health are from high-income countries in North America and Europe. Existing research typically focuses heavily on HIV among men who have sex with men, uses non-probability convenience samples, and applies frameworks to describe health inequities that emphasise risk behaviours rather than the agency and strengths of LGBTQI populations that can be leveraged. More research is needed to fill knowledge gaps in countries at all income levels and to examine multidimensional aspects of health, including non-communicable diseases and resilience.
A minority stress framework has generated important evidence on the relations between stigma and poor health among LGBTQI populations. This framework rejects notions of innate pathology and highlights the fundamental social and structural causes of health inequities. However, more research is needed on positive experiences and resiliencies in LGBTQI communities. Understanding how LGBTQI people cope and thrive can provide crucial information for the development of effective strengths-based interventions grounded in social cohesion and community connectedness. Longitudinal and cohort studies are needed to better understand how experiences across the life course affect the lives of LGBTQI people, not only by describing the accumulation of minority stressors, but also by exploring identity formation, access to social support, adaptive coping strategies, family formation, and healthy ageing.
Increasingly, research has identified variability in health experiences by sex characteristics, sex assigned at birth, gender identity and expression, and sexual identity and behaviour. For example, in North America, bisexual women have been found to experience higher rates of sexual violence and poorer mental health than lesbians. Studies across the globe indicate that HIV prevalence is higher in transgender people than in cisgender people, typically driven by clustering of structural and psychosocial factors. Attention to the specific health concerns of each group within the LGBTQI umbrella is important. Specifically, more research is needed broadly on the health of transgender men, lesbians, and bisexual people. Research with gay and bisexual men and transgender women rarely examines health issues beyond HIV; by contrast lesbian and bisexual women are under-represented in HIV research. Research with intersex individuals must move beyond a focus on surgery and sexual anatomy to explore broader aspects of health and rights-affirming approaches to intersex medical care.
LGBTQI people are diverse by sex, ethnicity, socioeconomic status, age, and ability, among other identities. More research is needed to understand how these intersecting identities converge, and the ways in which their associated privileges or disadvantages affect the health outcomes, health-care experiences, and priorities of LGBTQI people. An intersectional approach to health research with LGBTQI people locates the source of health inequities within systems of power, considers the interplay between social identities (eg, race) and inequities (eg, racism), exposes the negative impact of the status quo on marginalised communities, and centres the lived experiences and diversity of LGBTQI people.
Research questions and study designs must be guided by priorities and knowledge of LGBTQI communities to produce relevant data. In countries where aspects of sexual orientation and gender identity and expression are criminalised, data collection can be difficult; in such settings, researchers run the risk of state actors using LGBTQI data for entrapment, harassment, arrest, and persecution. The very criminalisation that interferes with quality data collection also drives health inequities that remain understudied and inadequately addressed. Work to fill gaps in LGBTQI health research must use community-based approaches to try to prevent harm to participants and misuse of data. Broader political and social efforts to protect LGBTQI people against criminalisation, violence, and discrimination based on sexual orientation and gender identity and expression are key to advancing LGBTQI health.
Although data gaps remain, interventions cannot wait. There are plenty of data on the stigma, discrimination, and social exclusion experienced by many LGBTQI people, and we know these experiences drive health inequities. Interventions must improve LGBTQI health and promote health equity. Interventions may span social–ecological dimensions, including: structural level policies and laws to protect rights and ensure freedom from discrimination; community level norms, values, and attitudes; interpersonal relationships; and intrapersonal domains of self-worth, self-acceptance, and internalised stigma. Interventions can be tailored for different groups—eg, reducing stigma in structural and social arenas among general populations, educators, and health-care providers or building resilience, stigma coping, and advocacy, and mitigating internalised stigma with LGBTQI people. Interventions tailored for stigma reduction and health promotion with LGBTQI people can use a life course approach that considers developmental stages, from childhood and adolescence, to emerging adulthood, parenthood, caregiving, and ageing. Importantly, implementation science research is needed to understand how interventions work, for whom, and in what context, so that they can be sustained beyond the end of research studies by government, non-governmental, and community actors.
No comments:
Post a Comment