By Heather Walter-McCabe
LGBTQ communities experience health inequities compared to heterosexual and cisgender peers. The health justice framework allows advocates to move the work upstream to the root causes of the problems, rather than placing a band-aid on the resultant consequences once the harm is caused.
It is not enough to provide individual treatment for the harm caused by stigma and bias. Health justice is a crucial means of ensuring that health care is equitable and that impacted communities are involved in policy and system advocacy.
The health justice framework, with its emphasis on community involvement in structural and governmental responses to systems-level transformation, must guide work in the area of LGBTQ health equity.
Understanding the types of disparities experienced by LGBTQ communities is essential to targeting solutions with high impact.
The disparities experienced in LGBTQ communities have been linked to numerous systemic factors, such as low rates of insurance coverage, increased stress due to systemic discrimination, and a health system which lacks cultural competency.
Depression, anxiety, PTSD, and substance use disorders are all experienced at higher rates in the LGBTQ community. LGB communities are two to three times more likely to attempt suicide than the general population, and transgender communities (inclusive of both binary and nonbinary folx) nine times more likely. In addition, LGBTQ communities are more likely to experience alcohol and substance use.
Lesbians may experience more severe outcomes for breast and ovarian cancer due to avoidance of care, often driven by fear of discrimination, lower rates of health insurance, and negative experiences with health care providers. Their fear is not unfounded, with over half of LGBTQ communities in the US experiencing discrimination in health care.
Accordingly, the health justice approach demands attention not only to health policy, but social policies, which hold promise for addressing these systemic factors.
For example, housing and social welfare policies are necessary interventions. LGBTQ communities experience a lack of housing at disproportionate rates, with youth experiencing more than double the risk of being unhoused than the general youth population. LGBTQ communities experience poverty at higher rates than their cisgender, straight peers. Bisexual ciswomen and transgender communities experience poverty at the highest rates within LGBTQ communities. All these indicators are even more significant with an intersectional lens, particularly among Black and Hispanic people within LGBTQ communities.
Another policy, marriage equality, provides a clear example of how social determinants influence health. Until 2015, marriage equality was only available in certain states. States that were early adopters of marriage equality showed positive impact on rates of health insurance, allowing access to spouses who previously were denied because they could not qualify as a spouse. Physical and mental health visits, as well as mental health costs, decreased in these states. Importantly, one study found a 7 percent decrease in the rate of self-reported suicide attempts in LGBTQ youth in states that passed marriage equality laws.
Conversely, in states passing constitutional amendments banning marriage equality, research showed increased psychological distress for LGBTQ communities. One study found a 250 percent increase in general anxiety disorders, an increase in alcohol use disorders, and psychiatric comorbidities. Similar increased were not present in states without such discriminatory constitutional changes.
Despite recent positive changes regarding marriage equality and workplace discrimination, LGBTQ communities are currently experiencing a resurgence of laws which institutionalize systemic discrimination. Laws criminalizing gender affirming care for transgender youth, restricting athletic participation of transgender youth, and religious exemptions to provision of both health care services and access to public accommodation are being proposed in state legislatures — in 2021 alone, thirty-three states proposed 100 such laws.
To achieve health equity in LGBTQ communities, health justice requires an examination of the root causes of the harm, those structural systems of bias and discrimination. A critical component of such work requires listening to true experts, leaders in and members of the LGBTQ community. The work certainly includes those laws which explicitly create barriers and create discriminatory systems in health care, but also laws around housing, wages, public accommodations, and even religious freedom, which is so often used to undermine the rights of LGBTQ communities.
Ensuring culturally competent care is readily accessible and easily available is an important goal in striving for health equity in LGBTQ communities, but without intervention in structural determinants of health, LGBTQ communities are unlikely to truly experience true health justice and equity.
Heather Walter-McCabe is an Associate Professor of Law and Social Work at Wayne State University Law School and Wayne State University School of Social Work.