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Healing between the margins

Addressing the health needs of diverse sexual and gender identities

The Gay and Lesbian Medical Association website states that, “patients should see their provider as an equal partner in their health care, not as a gatekeeper or an obstacle to be overcome.” Yet the reality for queer people seeking medical care is often quite different. Those of minority sexual identities often face adversity in the doctor’s office: be it discrimination, stigma, or even cost, these issues extend far beyond the reach of the waiting room.

One of the most harmful myths regarding LGBTQ healthcare is that queer people do not have health care needs distinct from the general population. Perhaps due to a willful refusal to recognize the unique LGBTQ struggle, this health care myth results from the conflation of queer people deserving equal rights as non-queers, with queer people having the same needs as non-queers, according to Allan Peterkin and Cathy Risdon’s Caring for Lesbian and Gay People: A Clinical Guide.

Facing the oppressive workings of heterosexism, queer people experience “minority stress” – a research term describing the chronic psychological distress associated with internalizing stigma and experiencing repeated incidents of prejudice. Countless studies have shown that oppressive social environments lead to very tangible negative health outcomes for queer people. This can include depression, anxiety, eating disorders, and substance abuse. Lesbians and gay men have been shown to be more likely to smoke, and lesbians are more likely to be overweight than the general population; both are more likely to suffer from heart problems. A study in the The Journal of the American Academy of Child and Adolescent Psychiatry connected risk of suicide in GLB teens with negative attitudes toward homosexuality.

The LGBTQ community has a precarious relationship with the health care system, sitting  atop a rocky foundation of a lack of awareness among health care providers, as well as a reluctance to engage with the health care system on the part of the queer population. There are many reasons that queer people choose not to engage in the traditional patient-provider model of health care services, the biggest reasons often being discrimination or judgment. Surveys of LGBTQ individuals show that many are reluctant to “come out” to their doctors, due to a fear of being judged or turned away.

Barriers to care include heterosexist environments fostered by aspects such as heteronormative language on medical forms, lack of awareness on behalf of health care providers, prohibitive costs as well as a lack of adequate insurance coverage, and a reluctance on the part of the patient or provider to discuss salient issues concerning sexuality and sexual history. Patient histories assume heterosexual sexual activity, or even a gender binary between man and woman.

Quinn Albaugh – a former Daily columnist on trans issues – stated in an interview that, “The onus is always on you to disclose information, and you may not be comfortable doing that. Finding a reliable physician whom you can trust is a lifelong challenge.” In fact, in the absence of a trusted doctor, many LGBTQ individuals put off seeking help until their conditions become aggravated, and they often fail to come back for follow-up care after the initial visit. The institution is in a state of transition, with the gay rights movement making strides that are perhaps not reflected equally across the board. For example, Albaugh talked about the awkward state of Quebec health care in covering sex-reassignment surgery operations. “They will cover it if you get it done at a public hospital, but there are no public hospitals that currently offer the surgery. So you have to go to a private clinic where it’s not covered,” they said.

Alongside high fees, potential stigma, or bureaucratic issues that may stop many people of non-normative sexual identities from seeking health care, transgender people also face an additional obstacle which homosexuals have generally overcome: having transgender status classified as a mental disorder within the Diagnostic and Statistical Manual of Mental Disorders IV (DSM), used in America and to varying degrees around the world. The pathologization of homosexuality has historically impeded the fight for gay rights and equality, though it was removed from the DSM as a mental disorder or “disturbance” in 1980. Nicola Brown of the national Centre for Addiction and Mental Health stated in an email that “because of the positioning of Gender Identity Disorder within the DSM, many trans people interface with mental health providers in order to be assessed for the World Professional Association for Transgender Health diagnostic and readiness criteria as part of their eligibility for hormonal and surgical treatments.” Yet these conditions may change, as the DSM-V is currently in preparation for publication in May 2013.

Danielle Chénier of the Association des transsexuels et transsexuelles du Québec (ATQ), an organization that maintains a list of trans-friendly medical resources and services, wrote in an email that especially for queer and trans people living in remote locations, access to care is hampered by a dearth of trained specialists – instead, they are referred to general hospitals which are often not equipped to deal with their needs. “Many transgender people end up discovering ATQ by chance, and we make sure that they are provided with good quality services and served by specialists who won’t exploit these people to line their own pockets,” Chénier wrote. Other similar organizations include Montreal’s Project 10, Stella, and the Concordia-run 2110 Centre for Gender Advocacy, all part of of the Montreal-based Trans Health Network along with ATQ.

Aid for the queer student

Though the situation seems bleak outside the hallowed halls of academia, queer students  at  anglo Montreal universities like Concordia and McGill have a much more robust resource network, and services that are considerably better-suited and aware of their needs. For instance, the 2110 Centre for Gender Advocacy is a powerful queer- and trans-friendly institution in Montreal, and also a student-funded Concordia organization catering to student interests, as well as those of the general community. Pierre-Paul Tellier, director of McGill’s Health Services, has worked at McGill for over thirty years and also works as a physician at Head and Hands – a non-judgmental and largely free clinic which is famously queer-friendly and trans-positive.

Albaugh noted that Tellier himself provides endocrinology consultations and prescriptions for a number of trans patients. More broadly, McGill’s SEDE (Social Equity and Diversity Education) Office provides safer space training for various bodies at McGill, including the counselling services, security, administration, faculty, and notably the health services. Albaugh notes, however, that “university students are in a place where they’re not quite financially independent. So navigating everything with your parents in terms of starting to transition [for transbodied students] can be an issue. Not having supportive parents can be a big deterrent to getting care, because they can always cut you off.” For many students, university is the first time to explore or determine sexual identities, and these resources are especially important in this context.

Ryan Thom, co-administrator of Queer McGill, believes that health services for students can be improved by making students feel more comfortable with using them. It may be the responsibility of the student to seek out help if they need it, but seeking help is easier if the environment is non-judgmental and discreet. Thom says, “Right now, of course, things are operated with an emphasis on the doctor-patient confidentiality policy, wherein to access McGill health services you have to provide your student ID and your legal name and other such information. I’d like to see more services available that are anonymous and specified as non-judgmental. … I would not only like to see a shift toward a more queer-friendly paradigm, but also a greater emphasis on general sexual health.”

Concordia University professor Deborah Dysart-Gale of General Studies Unit of the Faculty of Engineering and Computer Science wrote a review article in the Journal of Child and Adolescent Psychiatric Nursing arguing that nurses can leverage and provide better health services for queer teens. Dysart-Gale was quoted in The Science Daily on the topic of the suicides committed by queer youth last fall, “Bullying and such resulting suicides are avoidable. Health care workers have tools that can help queer teens – no one needs to die because of their sexual orientation.”