Increasing data on sexual orientation and gender identities in large scale social studies has revealed that significant portions of the Australian community are sexuality and/or gender diverse. In the 2014 ABS General Social Survey, 3% of the Australian population identified as not heterosexual, and whilst Australian data is unavailable, a study of 8500 New Zealand secondary school students revealed that 1.2% identified as transgender.
LGBTQIA+ refers to lesbian, gay, bisexual, transgender, queer and questioning, intersex, asexual and aromantic individuals, with the “+” connoting other diverse sexualities, sexes and genders. LGBTQIA+ Australians continue to face significant barriers to care which in turn impact individuals’ help seeking behaviours.[3, 4]
Until 1973, homosexuality was considered a mental disorder. Similarly, transgender and gender diverse (TGD) identities were classified as “gender identity disorder” until the 2013 edition of the Diagnostic & Statistical Manual (DSM-5)  and continues to be listed as such by the World Health Organizationís International Statistical Classification of Diseases and Related Health Problems (ICD-10). Furthermore, access to hormonal and/or surgical intervention largely remains tied to gatekeeper models requiring TGD individuals to be “diagnosed”.[6, 7]
Despite having been widely condemned as ineffective and causing significant psychological harm,[8, 9] pseudoscientific “gay conversion therapy” continues to persist. Most recently, a New South Wales GP appearing in a “Vote No” television campaign against same-sex marriage was identified as a founder of a “family values” group advocating this practice. Many intersex individuals have also been subjected to risky, non-consensual genital mutilation surgery as infants in a bid to “normalise” them. Furthermore, some clinicians expressly feel awkward treating LGBTQIA+ individuals. Hence, to effectively advocate for greater inclusivity and equity, it is paramount that health professionals understand both current and historical healthcare barriers as well as the specific health concerns of LGBTQIA+ communities
As such, this article will outline:
1) Effects of individual, interpersonal and structural social determinants of health on healthcare access for LGBTQIA+ individuals;
2) Key health issues affecting LGBTQIA+ individuals; and
3) Recommendations for improving access.
Social determinants of healthcare access for LGBTQIA+ individuals
Despite the acronym LGBTQIA+ construing homogeneity, LGBTQIA+ communities are distinctly heterogeneous. Individuals may have different experiences of their identity and come from different social contexts such as ethnic background or socioeconomic class. However, they do share a continued exposure to societal stigma associated with their diverse identities. This stigma plays into all levels of the social determinants of health which in turn impact both individuals’ health and healthcare access. These include individual internalised shame, interpersonal discrimination and ignorance and structural legal, administrative and systemic challenges. These determinants limit LGBTQIA+ Australians’ confidence in our healthcare system.
Individual and interpersonal
While accessing healthcare, LGBTQIA+ individuals face interpersonal barriers in the form of clinicians’ lack of knowledge and discrimination as well as their own individual internalised homophobia.
Many practitioners have limited training and awareness around the importance of comprehensive, non-judgmental sexual history taking. Clinicians’ unconscious biases often result in LGBTQIA+ clients being forced to “out” themselves in response to questions that assume heterosexuality and do not recognise gender diverse or intersex experiences (e.g. asking a trans woman about birth control). This exacerbates existing awkwardness around sexual and mental health and is associated with significant discomfort, which may contribute to patients’ decisions not to disclose their sexuality or gender identity. Additionally, some GPs did not understand different sexual practices and felt uncomfortable broaching the topic. One third of LGBTQ* Australians still hide their sexuality or gender identity when accessing healthcare. In youths, half did not disclose. This not only impacts individuals’ ability to build trust with healthcare providers but also undermines the provision of targeted health services such as human immunodeficiency virus (HIV) testing in men who have sex with men (MSM).
Healthcare providers’ lack of knowledge regarding TGD identities and unique health needs is a common theme.[17-20] Having to educate healthcare providers was found to be a key contributor to negative GP encounters in Australia. A lack of sensitivity [19, 20] with practitioners asking invasive or offensive questions  and misgendering clients through the use of incorrect pronouns or old names [15, 21] contributes to these barriers. Clinicians not working in TGD-specific fields often have little knowledge on the issue, resulting in these clients’ exclusion from mainstream health services.[2, 15, 21] Even clinicians regularly engaged with TGD clients enlist gatekeeping behaviours which restricts access to hormonal and surgical intervention.[17, 22] This discourages TGD individuals from raising mental health concerns and many find this process of “assessment” to be degrading and pathologising. Moreover, rigid, binary views of gender results in non-binary individuals feeling invisible and unwelcome to services.
Additionally, the view of LGBTQIA+ identities as inherently pathological by some providers is discriminatory.[13, 21, 24] TGD individuals may face clinician discomfort, disgust, ridicule, contempt and even refusal of treatment.[19, 21-23] One participant of the Australian and New Zealand TranZnation report was told by their doctor that she was “the filthiest, most perverted thing on earth” while another was informed they “needed to find god not hormones”. Asexuality is also pathologised. While DSM-5 now allows for self-identification as asexual as an alternative to diagnosis with “hypoactive sexual desire disorder” or “female sexual arousal/interest disorder” , historically, a lack of interest in sex has been pathologised by Western medicine.
Internalised homophobia may manifest as a further barrier to seeking healthcare services. Consequently, during periods of illness, individuals turn to pharmacies and only seek health services when self-medication has been unsuccessful.
LGBTQIA+ communities also face a myriad of structural barriers to quality healthcare.
Australia is currently the only Western country which requires TGD adolescents to gain Family Court ëapprovalí to access hormones. Despite the time-sensitive nature of hormone therapy, the legal process can take up to 10 months, and cost tens of thousands of dollars. However, this is currently under review by the Family Court.
TGD communities, especially non-binary individuals, also face inaccurate medical record keeping that do not reflect individual’s chosen names, genders and/or pronouns and a lack of gender-neutral bathroom access.[18, 23] Moreover, TGD individuals experience discomfort in gendered spaces such as gynaecologists’ clinics  and heightened discomfort surrounding pap smears and breast checks.[18, 22] The relegation of TGD services to the realm of expensive private healthcare is at heads with their increased risk of poverty, underemployment and housing instability.[18, 19, 23]
Furthermore, unconscious bias can also manifest in the distribution of research funding and practitioner training. Compared to the relative visibility of gay menís health around the HIV/AIDS epidemic, TGD health as well as queer womenís health have largely been ignored.
Key LGBTQIA+ health issues
Besides issues of access, LGBTQIA+ individuals have specific healthcare risks, needs and concerns. Pertinently, LGBTQIA+ individuals have significantly poorer mental and sexual health. They also have higher incidence of certain chronic diseases such as cardiovascular disease, asthma and diabetes.
Poorer mental health is one of the ways that stigma affects LGBTQIA+ individuals’ wellbeing. Compared to the general population, LGBTI people in Australia are five times more likely to attempt suicide in their lifetimes and more specifically, TGD-identifying individuals are eleven times more likely. LGBT people are also twice as likely to be diagnosed and treated for mental health disorders, and 24.4% of LGBT people aged 16 and over currently meet the full criteria for a major depressive episode.
Reasons for poorer mental health are also based in internalised, inter-personal, organisational and structural stigma and discrimination. These include: bullying at schools, lack of bullying laws, ostracism from families and faith communities, fear of employment and economic stability, and inner conflict and internalised phobia about their respective identities. LGBTQIA+ individuals also have higher risk for poor coping mechanisms and substance abuse.
LGBTQIA+ individuals may also experience poorer sexual health. There is evidence to suggest that women who have sex with women (WSW) are at higher risk for cervical cancer. Both patients and clinicians lack awareness around sexually transmitted infection (STI), specifically human papilloma virus (HPV), transmission during cisgender woman to woman sexual contact. Consequently, WSW are less likely to have Pap or other cervical smears.
In addition, MSM have greater incidence of HIV. In Australia, HIV transmission occurs primarily through male-to-male sex with 68% of new HIV diagnoses in 2015 having been attributed to male-to-male sex. Besides the greater susceptibility of anal mucosa, this increased incidence arises from the concentration of HIV within MSM sexual networks in Western nations. Receptive anal intercourse in male-to-male sex may also increase risk of hepatitis B, HPV and herpes. In NSW, MSM are also more likely to report ever having had an STI, particularly chlamydia, pubic lice, genital herpes, syphilis, anal warts and gonorrhoea. As some of these STIs are risk factors for anal cancer, MSM are also at greater risk for anal cancer. However, MSM are also more likely than any non-MSM to be tested for STIs.
Furthermore, poor data collection means that the sexual health of TGD populations in Australia remain poorly understood. The tendency to collapse TGD experiences into a single “third gender” category ignores the vast differences in risk associated with different gender identities, sexual orientations and partners. For example, the Kirby Institutes’ 2016 annual report on STIs recorded sex as “male”, “female” and “transgender/missing”. This is particularly disappointing in the context of trans women in particular being significantly overrepresented in global HIV prevalence.
Owing to Australiaís aging population, the issue of older LGBTQIA+ individuals is topical. LGBTQIA+ individuals in aged care have specific care needs such as ongoing HIV/AIDS treatment and hormone therapy. Having lived through the criminalisation of homosexuality, many may be impacted by an internalised need to go ëback into the closetí for fear of discrimination.
To reduce the aforementioned barriers and risks, various areas can be improved. Institutionally, education around LGBTQIA+ issues of sexuality, gender diversity, access and risk should be integrated into the medical curriculum. Trainees should be taught to adopt non-judgmental approaches to history taking and communication.[16, 40] Whilst questions such as “do you have a boyfriend/girlfriend?” seem innocent, they carry value judgements on what is considered “normal”. Instead, more inclusive terminology should be encouraged to enable clinicians to invite discussion around sexual health without assuming heterosexuality or gender binaries. Encouragingly, previous efforts in introducing LGBTQIA+ content through lectures and clinical simulations have been effective in decreasing at least clinician discomfort in providing LGBTQIA+ related care.[41-44]
Clinicians should also create environments of inclusiveness. This includes respecting patientsí chosen pronouns and names, and keeping open minds about their relationships. This is imperative to building trust. Introducing intake forms that include diverse gender identities and LGBTQIA+ specific signage or educational brochures also increase patient comfort. Additionally, revision of current data collection systems would enable more targeted healthcare delivery for TGD populations. This could be aided through mandatory recording of both sex assigned at birth and current gender identity which would enable the disaggregation of different TGD experiences.
LGBTQIA+ people face on-going barriers to healthcare on individual, interpersonal and structural levels and have an increased risk of mental, sexual and chronic illnesses. Thus, in order to improve health outcomes, barriers to access should be targeted on both interpersonal and structural levels. Ultimately, treating LGBTQIA+ people with individual respect and a willingness to learn will go a long way in in reducing these inequities.
Salwa Barmaky and Alexander Lee
Salwa is a fourth year medical student at the University of New South Wales. and a public health enthusiast, especially interested in health disparities and programme interventions.
Alexander is an undergraduate medical student currently studying at the University of New South Wales. His interests include improving healthcare access for marginalised populations including gender and sexuality diverse groups and reproductive health.
The authors acknowledge and thank Gale Chan for their contributions to the drafting and revising of this article.
©2008 laverrue, accessed from https://www.flickr.com/photos/23912576@N05/2942525739
Ryan melaugh, accessed from https://www.flickr.com/photos/120632374@N07/13974181800
Conflicts of interest
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