Invisible populations: LGBTQ people and federal health policy in Canada.
Mule, Nick J. ; Smith, Miriam
Gender and diversity have become central issues in health
policy-making. Increasingly, health policy analysis is grounded in
population health or social determinants of health approaches that
define particular populations as objects of policy intervention and that
consider the impact of social inequality on health status and outcomes
(Orsini 2007). This approach calls attention to the role of factors such
as gender, social class, indigeneity, and race in health policy
outcomes. Despite the increasing attention to gender and diversity in
health policy over the 2000s, however, there continues to be a
systematic lack of attention to lesbian, gay, bisexual, transsexual,
transgender, two spirit, queer and questioning (LGBTQ) (1) health
issues. This paper explores this lacuna, pointing to the exclusion of
systematic and explicit consideration of sexual orientation, gender
identity, gender expression and LGBTQ health, in federal health policy
discourse.
The exclusion of LGBTQ issues from federal health policy discourse
is important for a number of reasons. A wave of recent research has
highlighted the extent to which the social location of LGBTQ communities
and the discrimination and stigmatization experienced by these
populations may influence health outcomes in a range of other ways,
including higher rates of certain cancers, alcohol and tobacco use,
reproductive health issues, sexually transmitted infections (STIs),
barriers to accessing health care, lack of knowledge of medical
professionals, and specific mental health concerns (Canadian Rainbow
Health Coalition 2004; 2006; Jackson et al. 2006; Lehavot and Simoni
2011; Mule et al. 2009: 20-21). LGBTQ health is most often referenced in
relation to HIV/AIDS, which, from its emergence in the early 1980s,
affected gay men more frequently than other groups. More recently,
health issues affecting trans people have also been the subject of
public discussion, as several provinces, including Ontario, have debated
the funding of Sexual Reassignment Surgery (SRS) and other publically
funded medical treatments for trans people such as hormone therapy.
Aside from these areas, there has been little public debate in Canada
about the distinctive health needs of LGBTQ populations.
Moreover, over the period from 2004-2011, the LGBTQ community has
repeatedly called attention to health issues. A number of
non-governmental organizations have been formed to push the agenda of
LGBTQ health. The Canadian Rainbow Health Coalition, established in
2001, has undertaken a range of initiatives in LGBTQ health and,
although it has been relatively inactive over the last few years because
of lack of funding, its website contains a wealth of material on LGBTQ
health and wellness (Canadian Rainbow Health Coalition 2011). In
addition, funded services across Canada such as Avenue Community Centre
for Gender and Sexual Diversity Inc. (formerly Gay and Lesbian Health
Services) in Saskatoon, Rainbow Resources Centre in Winnipeg, Vancouver
Coastal Health and QMunity in Vancouver, and Rainbow Health Ontario have
been very active in putting forth LGBTQ health issues through provincial
health delivery systems and at a grassroots advocacy and education level
through the Rainbow Health Network based in Toronto (Rainbow Health
Ontario 2011). In addition, the lessons of the HIV / AIDS crisis of the
1980s, in which AIDS activists of the era intervened to shape health and
drug policies in an active way suggest that federal policy-makers should
be alert to the health concerns of particular groups such as the LGBTQ
community. Therefore, in addition to recent research that shows the gaps
in LGBTQ health provision, there is also political demand from LGBTQ
stakeholders for increased recognition in health policy-making and
delivery.
Such an approach would also be well-grounded in current health
policy templates and, especially, the dominant approaches to public
health, which routinely reference gender equity and social exclusion as
key components of health policy analysis, emphasizing the importance of
these factors to health and the importance of including all groups in
society in decision-making (World Health Organization [WHO] 2011).
Approaches to health policy-making such as population health and health
promotion both emphasize structural factors that influence health
outcomes and the role of prevention and education in determining health
and wellness. These templates fit well with the focus of biomedical
research on the LGBTQ communities as well as with the communities'
own demands for inclusion and consideration in health policy-making.
Another factor that might potentially facilitate LGBTQ inclusion in
federal health policy is that the government has attempted to take up
the discourse of gender-based analysis (GBA) or gender mainstreaming, an
approach that integrates gender into all aspects of policy-making and
that considers the ways in which policy choices--even when seemingly
gender-neutral--will affect women. Health Canada has been committed to
GBA since the early 2000s (Health Canada 2003: 6-7; on GBA in the
federal government in general, see Status of Women Canada 1996), while
GBA had been envisioned as part of the Public Health Agency of
Canada's mandate from its inception (for example, Women's
Health and Public Health Roundtable 2004). (2) The mandate of
gender-based policy analysis is to bring this gender lens into the
policy-making process, based on evidence, on the assumption that policy
will be more effective if it is based on a gendered lens rather than
designed in a gender neutral way (Hankivsky 2007). Sexual orientation
and gender identity are sometimes mentioned as additional diversity
factors when gender-based analysis is presented (Health Canada 2003: 9).
The government took a further step toward the recognition of sexual
orientation and gender identity in health policy by adopting Sex and
Gender-Based Analysis (SGBA) in 2009. This approach emphasizes the
importance of biomedical research on health differences between the
sexes, which are cast in a binary fashion; nonetheless, the SGBA policy
does recognize the concept of gender as a socio-cultural construction
(Health Canada 2010a). A number of observers have pointed out that the
adoption of GBA by the Liberal governments of the 1990s through the
2000s and the adoption of SGBA by the Harper government are hardly
unalloyed success stories when it comes to the recognition of the
interests of women in health policy (Rankin and Wilcox 2004; Paterson
2010). Nonetheless, the adoption of GBA and its expansion to SGBA should
trigger the consideration of LGBTQ interests in federal health policy,
especially given the political demand from the LGBTQ communities and
their advocacy organizations.
In this article, we specifically examine federal health policy
discourse and action, focusing on the major federal department that is
responsible for health--Health Canada--as well as the Public Health
Agency of Canada, charged with responsibility for public health. These
federal bodies are responsible for national discourses, models and
perspectives that shape concepts of health and health care in Canada
with international influence. Our purpose is to evaluate the extent to
which federal policy discourse incorporates LGBTQ health issues. While
the federal government is not responsible for the direct delivery of
health services to most Canadians, it does play a lead role in macro
level discourse and health care strategies that influence health care
delivery at the provincial and territorial level, where health care is
administered. We then explain the methodology we used to evaluate the
government's discourse, and we then present our findings that
suggest LGBTQ interests are marginalized and silenced in federal health
policy.
Methodology
In order to evaluate the federal government commitment to LGBTQ
health, we surveyed policy and research documents produced by Health
Canada and the Public Health Agency of Canada (PHAC) since 2004 and
sought interviews with Health Canada and PHAC officials. While policy
documents and research reports do not provide complete information on
the implementation of federal health policy, they do furnish a
reasonable basis for evaluating the federal government's health
policy discourse. The government's policy agenda is defined and
shaped by what it says about its own policies and research reports in
publicly available websites, policy and research documents, and
interviews. Even when research reports are not written by government
staff, but commissioned from outside consultants or produced in
partnership with other agencies, this research reflects the parameters
and priorities set by the government departments and agencies that fund
the research.
In order to develop a well-grounded picture of federal government
health policy, we searched the publicly available documents authored or
published by Health Canada and PHAC as well as searching the documents
available on the Health Canada and PHAC websites. Health Canada is the
main federal health ministry and PHAC is the main agency responsible for
public health. Given the range of health issues that have been raised in
biomedical research and in advocacy on LGBTQ health over the course of
the 2000s as well as the expansive recognition of LGBQ rights in
Canadian law over the same period (for example, through the passage of
the same-sex civil marriage legislation in 2005), we expected that
Health Canada and PHAC would offer some recognition of LGBTQ interests
in health. In addition to Health Canada and PHAC, we included some
documents that were authored, co-authored, or published by the Health
Council of Canada, the Canadian Institute of Health Information, and
Statistics Canada. The Health Council of Canada was established by the
federal and provincial governments to monitor the operation of health
care systems and health outcomes and is funded by Health Canada as part
of the federal-provincial health accords of 2003-4 (Health Council of
Canada 2009a). The Canadian Institute of Health Information (CIHI) is
funded by the federal and provincial governments to provide independent
health information (CIHI 2011). In addition, a number of documents were
authored by non-governmental researchers or in partnership with
non-government organizations, but were published by Health Canada or
PHAC. Statistics Canada, the federal agency responsible for the census
and other data, has a division responsible for health information that
sometimes publishes health reports in conjunction with PHAC or Health
Canada and these were included in the sample. We excluded the Canadian
Institutes of Health Research (CIHR) from the sample. As the main
federal granting agency for scholarly health research, CIHR operates at
arm's length from the federal government. Although it sets
priorities for health research, it does not control the applications it
receives nor does it approve or control the research results. Its
curiosity-driven research model does not directly reflect the federal
government's health policy priorities, which were the object of our
interest in this paper. (3)
In order to conduct the document analysis, we used the York
University library to collect Health Canada and PHAC-authored documents
published in English from 2005 to August 2011. Like most university
libraries, the York library is a depository for Canadian government
documents (York University Library 2011). The search for
English-language documents authored or published by Health Canada or
PHAC after 2004 yielded 367 results. As the purpose of the sample was to
evaluate the extent to which and the ways in which LGBTQ health was
discussed in federal policy discourse, the sample was culled to include
only publications on topics that could be defined as potentially
relevant to LGBTQ health. Topics were considered to be potentially
relevant to LGBTQ health if they had been identified in reports of
biomedical research, identified by LGBTQ stakeholder organizations such
as the Canadian Rainbow Health Coalition, identified in secondary
literature, or covered in the media. These issues included access to
health care, the (lack of) cultural competence of health care
professionals, higher rates of certain cancers (for example, breast
cancer for lesbians), domestic violence, sexual reassignment therapy,
hormone therapy, reproductive and sexual health, parenting, HIV/AIDS,
and mental health and addiction (see Canadian Rainbow Health Coalition
2011 for an overview of LGBTQ health issues). In addition, discussion of
specific populations such as Aboriginal people, youth, children, the
elderly, racialized minorities and migrants, immigrants or refugees were
included in the sample in order to see if LGBTQ people were mentioned or
considered to be part of these populations. In many cases, particular
health issues have been identified for LGBTQ people within these groups
such as, for example, the lack of appropriate care facilities for LGBTQ
seniors (Brotman, Ryan, and Cormier 2003), the lack of appropriate
housing and shelter for street-involved LGBTQ youth (Teotonio 2011) and
the bullying of LGBTQ youth in schools (Taylor and Peter 2011).
Topics that were not considered as potentially relevant for LGBTQ
health included areas such as workplace health and safety, vaccinations,
pandemic preparedness, food and chemical safety, and reports on drug
testing. (4) While these areas might affect LGBTQ health interests, they
have not been recently identified as such in the biomedical literature
or by LGBTQ health policy stakeholders, the criteria we used to define
"relevance" in the document analysis. In other words, the
sample was restricted to those areas where we might expect discussion of
LGBTQ health, based on health concerns that had already been identified
by LGBTQ stakeholders or in biomedical research. After culling the items
in this fashion and eliminating duplicates, the original search total of
367 English-language documents published from 2005-2011 was reduced to
172. In other words, 47% of the documents were deemed potentially
relevant for LGBTQ health. Of these, over one-third (36%) of these
documents (62/172) were searched at random and reviewed for mention of
LGBTQ health issues. In order to validate the findings from the document
search, we also conducted a Google search of the Health Canada and PHAC
websites to identify discussions that might not have been published in
official government documents.
Finally, we sought interviews with officials from Health Canada and
the Public Health Agency of Canada who were positioned in departments
and units that could potentially address policies related to LGBTQ
health. The intent was to target key policy makers at the intermediate
and senior levels. Within Health Canada five divisions were identified
and nine policy makers and one ministry official therein were approached
to participate in the study. Four divisions within PHAC were identified
and five policy makers were approached. Some indicated a lack of
availability during the data collection time period. Others indicated
that they did not have any knowledge of LGBTQ populations and/or that
their work did not expose them to these communities, and as such did not
see themselves being useful for our purposes, clearly indicating the
absence of policy attention to our subject matter. It is also possible
that the pending federal election of May 2011 may have dampened the
response rate for interview requests. In addition, the Harper government
has exerted strong and centralized control over the management of
information and this may have shaped the challenges we faced in
obtaining interviews (Delacourt 2011; Kozolanka 2009: 227-232;).
Nevertheless, we were able to undertake interviews with two Health
Canada civil servants, both of whom were interviewed in person at their
departments in Ottawa, as well as one civil servant from PHAC based in
BC, who was interviewed by phone in March 2011, and we include their
insights here.
Findings
Overall results in context
Table 1 presents the number of documents in the culled sample of 62
that included LGBTQ search terms such as "sexual orientation,"
"gender identity," "gay," "lesbian,"
"bisexual," "transgender(ed)" or "queer."
Of these documents, 14.5% contained at least one of the keywords. Table
2 indicates whether or not the reference to LGBTQ keywords was
substantive. If the LGBTQ communities were mentioned in passing (for
example, Health Canada 2010b: 84) or in a discussion unrelated to the
health topic (for example, Martin and Johnston 2008:18), the document
was classified as not substantive. If the document substantively
discussed some aspect of LGBTQ health (for example, PHAC 2010a; PHAC
2010b), the document was categorized in the substantive category. After
a careful review of the document sample, the results in Table 2 show
that LGBTQ health was substantively mentioned in only 8% of the total
document sample. The specific keyword counts ranged from 3.2% to 8% of
the 62 documents. The terms "gay," "lesbian" and
"bisexual" were mentioned most frequently at 8% while the
terms "transgender," "two spirit,"
"queer," "sexual orientation" and "gender
identity" were less frequently used. Given that the sample reviewed
was culled to focus on LGBTQ health and included issues of concern to
LGBTQ communities or issues identified as important for LGBTQ health in
the biomedical literature and by LGBTQ stakeholders, this result clearly
demonstrates that LGBTQ health issues have not been systematically taken
up by Health Canada and PHAC in their published policy discussions.
To put this result into perspective, we reviewed the same set of
documents for references to gender and gender-based analysis. Over
one-quarter of the documents mentioned gender (if only in terms of the
gender binary) and exhibited awareness that health research, needs and
outcomes might be different for women than for men. However, only about
10% of the document sample mentioned or engaged in gender-based
analysis, showing the weak level of commitment to GBA in the practice of
Health Canada and PHAC's documentary discussions and research
reports. Nonetheless, there was more discussion of gender and
gender-based analysis in this sample than of sexual orientation, gender
identity or any single LGBTQ keyword. This reinforces the view that
gender and gender-based analysis often do not include discussion and
consideration of sexual orientation and gender identity in the same way
that Hankivsky et al. (2010) has noted that health equity research often
overlooks intersectional analysis.
Our interviews with federal civil servants parallel the content and
website findings. LGBTQ people are not recognized for their broad health
and wellbeing issues in federal health policy, funding and programming,
nor as a designated population outside of STIs. GBA does not figure
strongly, and LGBTQ communities are not considered a part of the social
determinants of health model. When recognized, the LGBTQ populations are
seen as illness based and, as such, the federal government has not set
up any formalized systemic mechanism to address the broad health issues
of these communities.
Substantive content
The marginalization of LGBTQ health in these documents is even more
pronounced when the substantive content of the discussions is
considered. All of the documents that mentioned LGBTQ keywords in the
sample were qualitatively reviewed in order to assess the quality and
nature of the discussion of LGBTQ health, producing a short list of a
few documents that contained such substantive discussions. These
documents included PHAC's two pamphlets on sexual orientation and
gender identity in schools (PHAC 2010a; 2010b), the population studies
of HIV/AIDS (PHAC 2009a; PHAC 2011) and one other document produced for
the Mental Health Commission of Canada that mentioned LGBTQ health
needs, although without explicit discussion of the specific needs of
trans people (O'Hagan et al. 2010). Therefore, of the sample, only
five documents substantively discussed LGBTQ health over the course of
the decade.
Overall, most policy documents and research reports were resolutely
heteronormative and gender-normative; that is, they implicitly or
explicitly assumed an opposite-sex definition of couples and a
heterosexual sexual orientation (heteronormative) and failed to mention
gender beyond the traditional binary, thus excluding gender variant and
trans people. For example, discussions of treatment options for
Aboriginal youth with substance use problems recommended that youth
should be mentored and housed with peers of the same-sex, overlooking
the possibility of same-sex relationships or two spirit identities
(Chiefs of Ontario 2009). A PHAC document on pregnancy and childbirth
presents information on how to manage risks of childbirth with repeated
references to the "husband or partner" but without mentioning
female partners or gay fathers, thus eliding the reality of the growth
of queer parenthood (Public Health Agency 2009d: 1, 7; see also McCourt
2005; on queer parenthood in the Canadian context, see Epstein 2009). A
discussion of children's health presents family types, without
mentioning same-sex parents (Pollution Probe 2008). A discussion of
mental health in schools similarly avoided any mention of LGBTQ
populations, whether as students or parents, despite an extensive
discussion of bullying (Morrison 2010).
Moreover, there were areas in which we have expected the
incorporation of LGBTQ interests in health, given the identification of
these health issues in the biomedical literature as well as their
identification by LGBTQ health advocacy organizations, and yet they were
not discussed. For example, several biomedical studies have identified
the fact that bisexual and lesbian women (or women who have sex with
women--WSW) have higher rates of breast cancer than heterosexual women
(Kavanaugh-Lynch et al. 2002; Dibble, Roberts, and Nussey 2004;
Brandenburg et al. 2007). Yet, a PH AC guidebook on breast cancer
screening discusses breast cancer risk factors without mentioning
lesbian and bisexual women or the terms sexual orientation and gender
identity (PHAC 2009b). A guidebook on cervical cancer does not mention
gender, lesbian or bisexual women (PHAC 2009c). Discussions of
women's health equity from a population health perspective listed
ethnicity, income, education and geography as important factors within
each gender category (male and female) without further reference to
gender identity or sexual orientation (Bierman 2006). A discussion of
street-involved youth and the health risks of their sexual behavior did
not mention same-sex sexual behavior or LGBTQ people (PHAC 2006a; see
also PHAC 2007a; 2007b). Publications on access to care (that is, the
ability to access a knowledgeable family doctor), a major concern for
LGBTQ communities (Ryan, Brotman and Rowe 2000), did not refer to these
communities (Statistics Canada 2006; Health Council of Canada 2010).
Many other areas in which the LGBTQ communities might be expected to
have specific concerns and interests such as assisted human reproduction
(Health Canada 2006); addiction (Ahmad 2008), cancer (Canadian Cancer
Society 2007; Canadian Cancer Society 2010), public and stakeholder
communication about health risk (PHAC 2006b) and palliative, chronic,
and elder care (Health Canada 2007; Zierler 2010; Health Council of
Canada 2007; Health Council of Canada 2009b), did not include any
mention of LGBTQ people. The population-based reports on HIV/AIDS in the
Black and Caribbean communities and among First Nations provide some of
the only examples of intersectionality (PHAC 2009a; PHAC 2011). Other
reports and documents on Aboriginal health policy do not mention two
spirit people (for example, Health Canada 2009).
The most common frameworks for health policy discussion excluded
sexual orientation and gender identity. For example, the population
health approach was presented repeatedly in Health Canada and PHAC
documents and yet sexual orientation and gender identity were not
included as factors constituting specific populations (PHAC 2006a). A
report on Hepatitis C infection in Canada stated that "the renewed
Hepatitis C Program will ensure an evidence-based approach to policy and
program development, implementation and sustainability. Ongoing policy
and programming investment decisions will be based on a population
health approach that takes into consideration key health
determinants," which are listed as "income and social status,
social support networks, education, employment and working conditions,
social environments, physical environments, personal health practices
and coping skills, healthy child development, culture, health services,
gender and biology and genetic endowment" (PHAC 2009e: 12). A
discussion of community-based interventions to reduce health
inequalities focussed extensively on poverty reduction and
socio-economic determinants of health with no intersectional
consideration of poverty in terms of gender, race, sexual orientation,
gender identity or any other populations aside from youth and elderly
(Bell 2009: 3-12). A scan of the literature on how mental illness and
mental health are taken up in the Atlantic provinces made no mention of
the terms gay, lesbian, bisexual, transgender, sexual orientation or
gender identity, despite the fact that the report had been commissioned
with a mandate to explore the social determinants of health using a
population health perspective (Muzychka 2007: 3). This author
interviewed a number of people from the community and clearly received a
street level view of the need for more mental health services. Yet,
throughout her research, the mental health needs of the LGBTQ
population, which have been clearly identified in biomedical and
stakeholder reports, were not mentioned (Muzychka 2007). This example
demonstrates the extent to which the LGBTQ communities are submerged
from view in government-sanctioned health research, even when such
research is explicitly undertaken using a social determinants or
population health approach and even when it is based on a participatory
model of research (for a queer critique of the social determinants and
population health perspectives, see Mule et al. 2009).
This combination of social determinants and population health
approaches was typical in these policy documents, which often used the
terms interchangeably to refer to the social environment for health
policy and outcomes. A number of reports using the population health
approach listed socio-economic status, geography, culture, education and
other factors without reference to sexual orientation or gender
identity. This finding is consistent with discussions of population
health in the secondary literature that do not mention gender identity
or sexual orientation or mention them only in passing. For example, a
recent discussion of social determinants of health does include passing
reference to gay, lesbian and trans people in the discussion of gender,
although the discussion is limited to the health needs of LGT youth
(Mikkonen and Raphael 2010: 45); other dynamics of health inequity are
not considered from the perspective of gender and sexual diversity.
There were also examples in the sample of policy and reports that
took up an explicitly gender-based analysis without mention of sexual
orientation or gender identity or with only passing mention, reflecting
the extent to which S/GBA itself has been based on and has replicated
the heteronormative assumptions and the gender binary. For example, a
discussion of the development of women's health indicators moves
beyond GBA to diversity-based analysis, emphasizing "the
interaction between gender and the social determinants of health"
(Bierman 2006: vii). While the author argues that "gender and
equity analyses should be routinely incorporated into all Canadian
health indicator reporting initiatives" (Bierman 2006: vii), gender
is understood in binary terms and used interchangeably with sex. In
keeping with the focus on SGBA, the author deploys gender-based analysis
to show men's health situation, as they are more prone to binge
drinking and other conditions. The author is critical of previous work
that has mentioned gender but did not undertake a gender-based analysis.
Ethnicity, income, education and geography are all identified as
important factors within each gender category (male and female). This
document was one of the few to incorporate an extensive discussion of
race, using the terms race, and migration, but gender was not deemed to
include the LGBTQ populations, either on their own, or as subsets of
other groups (Bierman 2006: 2-7). Similar results were found in other
documents covering topics such as addiction (PITAC 2007b; Ahmad 2008),
among others.
Even when LGBTQ issues are taken up, federal policy discussions do
not centre the LGBTQ population itself. For example, Health Canada and
PHAC's population-based reports on HIV/AIDS in Canada focused on
the Black and Caribbean population and the Aboriginal population,
extensively discussing LGBTQ identities in these communities (PHAC
2009a; 2011). This intersectional perspective is important and
highlights the challenge of LGBTQ identities in these communities, as
the reports argue that it is more difficult for Black Caribbean and two
spirit people to come out in their communities. The reports also discuss
violence specifically directed against women and girls, trans and bi
people and people with disabilities, thus showing an awareness of gender
and diversity-based analysis (PHAC 2009a 4-6, 37ff). However, LGBTQ
populations appear in the population-based studies only through their
membership in other population groups. Given that gay and bisexual men
constitute 48% of HIV/AIDS cases in Canada, the lack of a specific
population study of the LGBTQ communities is a lacunae and one that has
been pointed out by LGBTQ stakeholders in HIV/AIDS policy (Garro 2009).
Acknowledging gay and bisexual men under other social locations (that
is, racialized, ethnicized cultures) or absenting them altogether, is in
effect invisibilizing those that are out and proud as gay and bisexual
men and their social location on the cultural map (Mule 2005; Young and
Meyer 2005). Perhaps in part in response to this criticism, PHAC has
recently stated that it would undertake a population study of gay, two
spirit and bisexual and other men, although this report, if completed,
did not turn up in our document search (PHAC 2012). In addition, the
lack of discussion is occurring at a time when controversies over the
criminalization of PWAs are on the rise (Fagan 2011) and in a context in
which stable federal funding for HIV/AIDS prevention among gay and
bisexual men is lacking (Barsotti 2010; D. Smith 2011; Salerno 2012).
The discussion of HIV/AIDS is a key example of the way in which
LGBTQ health is currently situated in federal policy. While HIV/AIDS is
a longstanding issue in the LGBTQ communities, sparked the establishment
of early queer health organizations such as the AIDS Committee of
Toronto (ACT), and continues to affect a large number of gay and
bisexual men, their status in HIV/AIDS health research and service
delivery is contested. Despite the fact that these men are
disproportionately affected by HIV/AIDS (Jaffe, Valdiserri, and De Cock
2007; Sullivan, et al. 2009), gay, bisexual and other men were not
singled out as a population according to the document search. Moreover,
in an attempt to focus on behaviour rather than identity for purposes of
public health, HIV/ AIDS research and policy sometimes deploys the
epidemiological terminology of men who have sex with men (MSM) and, at
times, writes of HIV/AIDS and of same-sex sexual behaviour without ever
referring to LGBTQ identity (Mule 2005; Young and Meyer 2005). For
example, a recent report on a joint UN/Health Canada/PHAC consultation
on disability and HIV/AIDS focuses on people with disabilities and
people with HIV/AIDS without mentioning LGBTQ populations. The report
also mentions that many stakeholder groups were invited to the
consultation as well as individuals from the education, service and
research communities. There is no mention of LGBTQ groups having been
invited to these consultations, although, undoubtedly, many members of
the communities would have been involved as members of other
organizations or as people with disabilities or people with HIV/AIDS.
However, these intersections are simply invisible in the report.
Similarly, although there is some discussion of the specific situation
of women with HIV/AIDS, the word gender does not appear in the document
nor does the term gender-based analysis (Joint United Nations Programme
on HIV/AIDS 2009: 10-12, 19, 21).
Websites
In order to obtain another view of the public discussion of LGBTQ
communities by the federal government and in order to validate our
results from the document search, we also used Google to search the
Health Canada and PHAC websites. Websites are an important aspect of the
public presentation of health discourse and may contain additional
resources that are not captured by formally published government
documents. We used Google's Advanced Search to conduct
site-specific searches for LGBTQ keywords as well as comparator keywords
over the period 2004 to August 2011 on the Health Canada and Public
Health Agency of Canada websites. There were 17,500 mentions of the word
"health" on the Health Canada website, but only 45 mentions of
the word "gay," 34 mentions of the word "lesbian,"
19 mentions of the word "bisexual," 14 mentions of the term
"transgender," 6 mentions of the term "gender
identity" and 25 mentions of the term "sexual
orientation." Most mentions of lesbians and all mentions of
bisexuals and transgender people occurred as part of the umbrella term
LGBTQ, rather than as a discussion of specific lesbian, bisexual, or
transgender health issues. The search of the Public Health Agency of
Canada website covering the same period found better representation of
LGBTQ populations. There were 131 mentions of the word "gay"
on the PHAC website; however, 90 of them mentioned gay men in relation
to HIV/AIDs or other sexually transmitted infections. Interestingly,
PHAC links gay men with HIV/ AIDS through its website. Yet, like Health
Canada, it fails to do so in its more comprehensive documents that
impact health policy. The other 41 documents on the PHAC website
mentioned gay men (usually as part of the LGBTQ group, rather than on
their own) in relation to a few other health issues including mental
health, domestic partner abuse and, in one case, homophobic bullying of
gay youth. Many other health-identified issues were not mentioned,
however. For specifically lesbian issues, there were only eleven
mentions, most of them on intimate partner violence, certainly an
important issue, but far from the only public health issue affecting
lesbian women, according to the secondary literature and according to
LGBTQ stakeholder organizations. For bisexuals, there was only one
specific mention, aside from their inclusion under the umbrella of LGBTQ
and this was a substantive discussion of the risk of intimate partner
violence for bisexual men compared to straight men. Tellingly, the term
"transgender" had the lowest number of total hits on the PFIAC
website, at 36, most of them overlapping with the LGBTQ category and all
but three focussing on HIV/AIDs. Only one document on the PFIAC website
specifically discussed trans health issues. These findings confirm the
results of the document analysis and the exclusion of discussion of
broad LGBTQ health issues from the public presentation of Canadian
health policy by Health Canada and by the Public Health Agency of
Canada.
Beyond publicly accessible documents, we also pursued interviews
with civil servants in Health Canada and PHAC involved in policy
development. The challenges in obtaining interviews are consistent with
our research results. Those we approached claimed not to work on LGBTQ
issues and were unable to refer us to those who did. Of those who
considered our request, three-two from Health Canada and one from
PHAC-agreed to participate.
Interview results
Several key themes emerged from the data gathered from interviews
with three federal civil servants that provide relevant insights into
the development of LGBTQ-sensitive policy. The interview subjects
confirmed that, at best, LGBTQ communities are thought to be included in
illness-based HIV/AIDS/STI policies or diversity-based policies, the
latter of which focuses strictly on "sexual orientation,"
ignoring trans issues. The interview participants questioned the
influence of GBA in the federal government and argued that, if anything,
it appears that community-based groups and organizations contribute to
shaping policy and programming based on their feminist analysis and
mandates more so than the government's commitment to GBA. Regarding
the Social Determinants of Health model, one interviewee questioned why
the government has not captured LGBTQ populations within it, given the
obvious fit.
Although respondents were clearly in touch with the LGBTQ
communities and did receive issues and concerns regarding their health
and wellbeing, what is lacking is a formal governmental systemic vehicle
with which to address the broad health concerns raised by the LGBTQ
communities. Recommendations from final reports of federal
government-funded community-based LGBTQ health research studies were
neither formally followed up, nor was an environment created that
encouraged policy makers to do so. These recommendations essentially
called for governmental recognition of broad health issues, needs and
concerns of LGBTQ people with corresponding education, research, policy,
programming and funding. Many called for a formalized government-backed
systemic initiative that would ensure these components are properly
resourced and implemented. This lack of priority and minimized
recognition meant that LGBTQ individuals were generally consulted
regarding HIV/ AIDS/STIs but not regarding other health issues. In this
way, the interview participants confirmed the federal government view of
the LGBTQ communities as illness-based rather than socially located or
positioned. Despite numerous federal government-funded community-based
LGBTQ health research studies, health-based LGBTQ funding was not
extended for broad health and wellbeing issues. Yet, funds were extended
for public awareness campaigns regarding STIs codifying the LGBTQ
communities as sexualized and dangerously so. The interview participants
also pointed to the role of fear and ignorance in limiting attention to
and inclusion of LGBTQ communities. In sum, the interview results were
consistent with the findings of the document analysis and website
searches.
Conclusions
Despite (some would argue in spite of-see Garro 2009) federal
policy templates such as population health and the social determinants
of health and the commitment to undertake a Sex and Gender-Based
Analysis (S/GBA) in policy development, LGBTQ communities are, for the
most part, absent from federal health policy. Although S/GBA is now
official policy at the federal level, its traditional assumption of
binary notions of the genders falls far short of even beginning to
adequately address the complex and diverse health-related issues
affecting LGBTQ populations. Where LGBTQ people are acknowledged tends
to be in HIV/AIDS/STI-specific initiatives, with an emphasis on MSM.
Although these illness-based policies entail funding, programming and
services that by extension benefit gay and bisexual men, they further
marginalize the health needs of lesbians, bisexual women and the
transgender populations, not to mention the broader health and wellbeing
issues of LGBTQ communities in general. It is well established that
LGBTQ communities experience a series of distinct health and wellness
issues and concerns as found in the formal and grey literature, and has
become a focus for organizing and political action within the LGBTQ
movement over the past 12 years. Yet, federal health policy discourse,
with few exceptions, has all but ignored these needs.
Our findings show that both Health Canada and PHAC have
underrepresented LGBTQ communities' health issues in their
respective published policy documents, demonstrating a systemic
oversight. Although GBA was taken up more so than gender and sexual
diversity issues, it too fell short compared to the perspective of
gender, the latter of which was strictly defined in binary terms. The
lack of intersectionality between GBA and LGBTQ people is remarkable,
even when the illness-based issue of HIV/AIDS is taken up. When LGBTQ
communities were mentioned, they tended to be of secondary concern.
Whether it was the population health or social determinants of health
models or the PHAC and Health Canada websites, LGBTQ health issues were
minimally addressed at best with the exception of HIV/AIDS. Both Health
Canada and PHAC would do well to equally acknowledge MSM and gay and
bisexual men, their respective social locations and differing health
needs as a result. Additionally, these federal health departments need
to take up the array of health and wellbeing issues affecting the LGBTQ
communities based on the literature.
The interviews we were able to conduct speak to a limited
illness-based (HIV/AIDS) focus that does not take up LGBTQ people as a
population with distinct health and wellness issues in any of their
health models. The participants acknowledged that the health issues of
LGBTQ communities were not a priority. As such, they were hard pressed
to point to funding, programs and services that addressed LGBTQ health
concerns outside of HIV/AIDS/STIs. They confirmed that no direct link
exists between S/GBA and gender and sexual diversity. They spoke of a
lack of political will and leadership from within that would champion
these issues, alluding to a systemic ignorance and apathy that is
leaving the LGBTQ population with little support at the federal level.
Although the few interviews we conducted is a limitation of this study,
the participation of and information provided by these individuals in an
environment that discourages such participation is noteworthy.
A future study might also seek to explore the reasons for the
federal neglect of LGBTQ issues, a neglect that has spanned both Liberal
and Conservative governments. As a minority group that is not able to
mobilize substantial electoral pressure, the LGBTQ community has
benefitted from political alliances with Liberals, and especially, with
the federal NDP over the years. Yet, most of the main changes in federal
and provincial policies toward the LGBTQ community in Canada, especially
on issues such as same-sex marriage and relationship recognition,
occurred as a result of litigation, as the LGBTQ movement was able to
exploit the political opportunities created by an empowered judiciary in
the wake of the constitutional entrenchment of the Charter of Rights
(Smith 1999; 2008). The integration of LGBTQ interests into other
aspects of policy-making is a challenge in the absence of electoral or
legal pressure. The project of explaining the position of LGBTQ
communities in Canadian health policy naturally flows from this paper,
which has presented an empirically-based description of the absence of
the community from federal health policy discourse.
As a population that has suffered years of discrimination and
marginalization, the LGBTQ movement fought for equitable representation
and recognition, including protection on the basis of sexual orientation
in human rights legislation (this battle continues on the gender
identity and gender expression front). Yet, as demonstrated in this
study, the federal health system has not adequately taken up these
issues in a manner that would effectively address LGBTQ health needs.
Given that health care is administered at the provincial and territorial
level, future research can explore whether these populations are better
recognized at that meso level. Nonetheless, the role of federal health
programs is not to be underestimated in setting a pan-Canadian health
discourse as a guide for the provinces and territories to follow. The
Canadian federal government can redress this situation by allowing for a
more inclusive, diversified approach to its health care perspectives
encapsulating the LGBTQ populations.
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Notes
(1) For the purposes of this paper, LGBTQ denotes lesbian, gay,
bisexual, transgender, transsexual, two spirit, queer and questioning
people. This encompassing acronym captures sexual orientation regarding
those sexually attracted to the same sex (lesbians, gay men) and both
sexes (bisexuals); gender identity and gender expression (transgender,
transsexual) that involves identifying with a gender that differs from
the biologically assigned gender at birth (which may or may not conform
to binary genders and may or may not involve sex reassignment surgery);
the sometimes contested Aboriginal notion of two genders within one
person (two spirit); the politicized identity of queer that celebrates
difference and resists heteronormativity; and those questioning their
sexuality, gender identity or gender expression.
(2) The Public Health Agency of Canada was established in 2006.
However, discussion of its potential gender mandate occurred prior to
its establishment (for example, Women's Health and Public Health
Roundtable 2004).
(3) In future research, it would be useful to explore the ways in
which CIHR's priorities have been set, and the effect this has had
on research on gender and sexuality.
(4) Drug testing was excluded, as there were no specific
controversies affecting the LGBTQ populations over the period of this
study (2004-mid 2011). This would not be true of other historical
periods (on the U.S., see Epstein 1996).
Nick J. Mule is associate professor, School of Social Work, York
University, Toronto. Miriam Smith is professor, Department of Social
Science, York University, Toronto, Ontario.
Table 1. Total LGBTQ Keywords in a Sample of Health Canada and PHAC
Publications 2005-2011
Total Keywords
as % of total
# of documents document
that mentioned sample
Keyword keyword (62 documents)
gay 9 14.5
lesbian 8 12.8
bisexual 6 9.6
transgender 3 4.8
two spirit 2 3.2
queer 2 3.2
sexual orientation 3 4.8
gender identity 3 4.8
total * 9 14.5
Source: Health Canada and PHAC document sample taken from York
University library catalogue, August 2011. * Most of the keywords
appear together in the same document. Therefore, the totals do not
add.
Table 2. Substantive v. Non-Substantive Discussion of LGBTQ
Keywords in a Sample of Health Canada and PHAC Publications
2005-2011
Substantive
# of documents as % of total
that mentioned document sample
Keywords keyword (62 documents)
gay 5 8
lesbian 5 8
bisexual 5 8
transgender 2 3.2
two spirit 2 3.2
queer 2 3.2
sexual orientation 2 3.2
gender identity 2 3.2
total * 5 8
Not Substantive
# of documents as % of total
that mentioned document sample
Keywords keyword (62 documents)
gay 4 6.5
lesbian 3 4.8
bisexual 1 1.6
transgender 1 1.6
two spirit 0 0
queer 0 0
sexual orientation 1 1.6
gender identity 1 1.6
total * 4 6.5
Source: Health Canada and PHAC document sample taken from York
University library catalogue, August 2011. * Most of the keywords
appear together in the same document. Therefore, the totals do not
add.
