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PART ONE
Key issues in social work with LGBT people
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ONE
Much to be desired: LGBT health inequalities and inequities in Canada
Nick J. MulƩ
Introduction
Canada is commonly seen as a progressive country with its multicultural model, its tolerance for diversity and its sensitised human rights legislation (Elliot and Bonauto, 2005). Although Canada can be commended for the progress it has made in each of these areas, one need only scratch the surface to expose the inequalities and inequities that lie beneath.
Lesbian, gay, bisexual and trans (LGBT) populations are a clear example of a people who were once unrecognised culturally, neither tolerated nor accepted socially, and completely devoid of inclusion in human rights legislation and its ensuing protections in Canada. The last 45 years have seen momentous shifts in each of these areas, so much so that it has produced a near utopian veneer that serves to mask continuing forms of oppression and micro-aggressions that simmer from below. Despite the elevation of Canadaās LGBT communities as a recognised population that makes up part of the multicultural fabric of the land, with near full recognition of human rights protection in legislation, LGBT people fall woefully behind the general population with regard to health and wellbeing. HIV/AIDS continues to be the illness-based focus that the Canadian state gives varying degrees of support to, barely recognising the broader health and wellness issues, needs and concerns that affect LGBT Canadians.
Two models have informed health policy in Canada (with international influence), which have progressively focused on diversity, given the multicultural make-up of the country, with varying success:
ā¢ the world-renowned āHealth Promotionā model (Government of Canada, 1974), which focused on achieving a healthy lifestyle;
ā¢ the internationally regarded Population Health model (Health Canada, 1998, 2001), which more explicitly identifies diverse populations and attempts to address the social determinants of health (SDoH) (Public Health Agency of Canada, no date).
Neither have completely addressed LGBT people as a population that experiences health inequalities: the former was critiqued for its lack of attention to structural differences; and the latter fell short, due to its over-emphasis on determinants of health at the expense of āsocialā aspects ā becoming mired in unsatisfactory notions of āhealth cause and effectsā (Orsini, 2007). Victim blaming becomes the focus in a responsibilisation paradigm backed by social and political forces that, for example, can easily attach responsibility on an individual for becoming infected with HIV, who is presumed armed with information to protect themselves, yet the system pays far less attention to access and understanding of such information, proper use of safe drug-use kits, faulty condoms, āheat of the momentā behaviours and risky behaviour engaged in by one of the partners, among other complex scenarios. Underscoring such foci is the influence of neoliberalism (Duggan, 2003), which places responsibility squarely on the shoulders of individuals (Lupton, 1999; Petersen and Brunton, 2002), absolving the state of its responsibility (Foucault, 1979; Murray, 2007) to promote and accommodate a healthy citizenry. What is lost in the individualisation of such a concern as health is the welfare stateās role in its collective redistribution that is overwhelmingly cisgendered and heteronormatively framed.
Since the early 2000s, Health Canada ā the government department responsible for the national health policy ā has attempted to implement a policy development method known as gender-based analysis (GBA) (Health Canada, 2003, pp 6-7) or gender mainstreaming. This approach takes gender into consideration in all aspects of policy making, including that of policy choices and how they will affect women, even when seemingly gender neutral. Although initially located in Health Canada and influencing the establishment of the Public Health Agency of Canada, GBA, more recently updated to sex-and-gender-based analysis, was also intended to affect all federal policy making (Health Canada, 2010). To date this has not been the case, nor has it taken on a more nuanced understanding of gender, particularly from the perspectives of gender identity or gender expression. Despite increased state attention to diversity, including that of gender in health policy throughout the 2000s, simultaneously there was and is a systematically narrowed gaze, if any, given to LGBT health issues.
Most often referenced, when it comes to LGBT health, is HIV/AIDS, which from its crisis-induced emergence in the early 1980s, predominantly affected gay men more so than other groups. Recently, the health issues of trans people have also arisen within healthcare discourses, as several provinces debated the funding of sex reassignment surgery (SRS) and hormone therapy among other publicly funded medical treatments for these populations. Aside from these issues, usually taken up within health circles, there has been little public discussion in Canada regarding the distinctive health needs of LGBT people. Yet, increasingly research has highlighted the extent to which the social location of LGBT communities along with the discrimination and stigmatisation experienced by these populations influence health outcomes. Examples of health disparities, amenable to social work intervention, include:
ā¢ higher rates of certain cancers (Fish and Wilkinson, 2003);
ā¢ alcohol, drug (Senreich, 2010) and tobacco use;
ā¢ reproductive health issues;
ā¢ (dis)abilities (Shildrick, 2004);
ā¢ specific mental health concerns (Hooghe et al, 2010; Volpp, 2010);
ā¢ young peopleās issues (Toomey and Richardson, 2009);
ā¢ older peopleās issues (Concannon, 2009).
Also, there are larger systemic issues such as barriers to accessing social work and healthcare, professionalsā lack of knowledge about and erasure of LGBT people from public health structures and initiatives and so on (MulĆ©, 2007; MulĆ© et al, 2009, pp 20-1; Lehavot and Simoni, 2011).
Research into such matters was often spurred by the LGBT community itself who undertook a number of community-based studies as early as the 1990s, then throughout the 2000s increasingly calling attention to their broad health and wellbeing issues (CRHC, 2013; Rainbow Health Ontario, 2013a). Prior to and during this time, non-profit organisations sprung up offering broad health and wellness services, information and coordination apart from the highly established AIDS service organisation (ASO) structures. Yet such LGBT research and organising with regard to broad health and wellness concerns for these populations fly largely under the radar of formalised policy structures (Smith, 2007). The existence of LGBT people in society is marked with marginalising effects by their absentia in public policy. Implications of such erasure can be felt materially due to a lack of funding, programmes and services (Carabine, 2004a; MulƩ, 2005). In essence, this has heteronormalising implications in which heterosexuality, by its very presence and acknowledgement in public policy, is reified as the norm, casting notions of abnormality on sexualities that fall outside such narrowed discourse (Carabine, 2004b).
This chapter explores the hidden lacunae, highlighting the paradox of Canadaās commitment to health policy templates that purport population-based health and SDoH matters, and the stateās lack of substance in considering the broad health issues of LGBT people. A brief description of how public health is administered in Canada is provided, followed by how such broad LGBT health issues are taken up in light of the continued dominant focus on HIV/AIDS regarding health issues and LGBT communities. Variances in approaches across a number of Canadian provinces and municipalities are reviewed. How social work is implicated by the governance of these issues both by the Canadian state and by the professionās governance structure in Canada and internationally is discussed. An argument is then made, based on a critical analysis of Canadaās surface consideration of LGBT people, for a more substance-driven alignment with health policy templates that would provide meaningful health and social care benefits.
Structural landscape of public health administration in Canada
In Canada, federal health policy discourse and action are governed by federal departments Health Canada as well as the Public Health Agency of Canada, respectively charged with overseeing and providing guidelines for health and public health. These federal bodies are responsible for national discourses, perspectives and models that shape conceptualisations of health and healthcare in Canada, which have and continue to wield international influence. While the federal government does not engage in direct delivery of health services to most Canadians, it plays a lead role in developing and disseminating macro-level discourse, healthcare strategies and funding that influence healthcare delivery at the provincial/territorial level where healthcare is administered. The focus of this chapter, for the most part, is at the national level and the influence the Canadian federal government has on addressing the health issues of LGBT populations, while also featuring how a number of provinces and communities are innovating to address the same.
An illness-based HIV/AIDS focus ā broader LGBT health issues overshadowed
Since 1990, the Canadian government has spent millions of dollars on numerous AIDS strategies and initiatives (CIHR, 2008). Over the years, government attention to the illness has resulted in a highly structured system of ASOs at the federal, provincial/territorial and municipal levels attempting to contain the spread of the virus and provide supports for those affected. Although Canada has benefited greatly from antiretroviral drugs that have essentially changed the dynamics of the virus from a terminal illness to a chronic illness managed with medications (CATIE, 2013), HIV/AIDS continues to dominate the LGBT health focus. While the Canadian AIDS initiative has become so established and essentialised, broader health and wellness concerns of the LGBT communities have been neglected for years and continue to struggle to get governmental support.
Simultaneously, Canadian LGBT communities also established non-governmental organisations (NGOs) at the national, provincial/ territorial and local levels, advocating for a broader agenda of LGBT health and wellbeing. One such national organisation is a case in point. The Canadian Rainbow Health Coalition (CRHC), established in 2001, has undertaken a range of broad-based LGBT health and wellness initiatives. Yet, it has suffered of late in not being able to access state funding, due to a non-HIV/AIDS focus and a conservative federal government generally unsupportive of the LGBT populations. Nevertheless, the CRHC website contains a wealth of material on LGBT health and wellness (CRHC, 2013).
Provincial administration of health services to the LGBT communities is uneven, with varied approaches across Canada. In British Columbia and Ontario, the Vancouver Coastal Health (2013) and Rainbow Health Ontario (RHO) (RHO, 2013a) respectively offer information and referral resource programmes for LGBT people. Additionally, RHO provides a comprehensive website, LGBT training for healthcare providers and liaises with LGBT community outreach workers in each of the 14 Local Health Integration Networks (LHINs) in Ontario. Similarly, Nova Scotiaās Capital Health provides āprideHealthā ā a health initiative for gay, lesbian, bisexual, trans, intersex1 and queer2 (GLBTIQ) people, offering resource and referral information primarily in the Halifax region (Capital District Health Authority, Nova Scotia, 2013).
By contrast, in QuƩbec, a major policy initiative was undertaken with the release of its QuƩbec policy against homophobia (Justice in QuƩbec, 2009). This is a comprehensive policy that acknowledges the existence of homophobia, with a wide-reaching set of strategic guidelines to address it within the provincial public sector. One such guideline is to promote wellbeing, with strategic choices such as:
ā¢ providing support for victims of homophobia;
ā¢ promoting the adaptation of public services;
ā¢ providing support for community action.
For example, victim services in social work/social care are urged to become sensitised to and develop interventions for LGBT-targeted bashings. QuĆ©bec is the only province in the country to take such a unique approach ā a macro systemic perspective on addressing homophobia in public services via a sweeping provincial policy. This strategy goes beyond sole-based provincial coordination services with limited funding to embedding anti-homophobia measures structurally within the QuĆ©bec government and its ensuing policies, services and programming.
Funded services at the municipal level across Canada include the following, which have all been active in addressing LGBT health issues through provincial health delivery systems:
ā¢ Avenue Community Centre for Gender and Sexual Diversity Inc. in Saskatoon, Saskatchewan;
ā¢ PTS in Ottawa, Ontario;
ā¢ QMunity in Vancouver, BC;
ā¢ Rainbow Resources Centre in Winnipeg, Manitoba.
Both the Rainbow Health Network located in Toronto and The Well in Hamilton are grassroots advocacy groups that address LGBT health issues and provide public education without any state support, except for occasional project-based funding (Rainbow Health Network, 2013; The Well, 2013).
Many of these groups and organisations have developed due to community-based research, sometimes funded by the federal government. Their sporadic existence throughout the country highlights the few voices doing ongoing advocacy work, and the political demands for formal structural recognition in health policy making and delivery. Such NGOs have taken on responsibility for providing services to tackle health inequalities that have not been provided through mainstream services.
Critical implications for social work
Social work practice
Social workers play a prominent role in the provision of health and social care related services to the LGBT populations, whether they be government funded or not, within mainstream services or specialised (including many described in the previous section), illness-based such as HIV/AIDS or broader. In contrast to biomedical interventions, which focus primarily on addressing downstream health issues such as the mental and physical effects of health problems (for example, homelessness, survival sex work, suicidality, depression, substance use, HIV and other sexually transmitted infections), social work is well positioned to take an upstream role via the SDoH towards the mitigation and prevention of such problems. The social worker can carry out such practice via means of recognising, acknowledging, ensuring representation of and prioritising such issues specific to LGBT people in social and health systems that overlook them. For example, social workers can intervene by providing support for same-sex parenting, advocating for supports for LGBT young people, responding appropriately to domestic abuse in LGBT communities and promoting independence among older LGBT people.
Social workers can play an influential role in mainstream as well as specialised LGBT health and social care services and society in general. Such a role can be varied, whether it be through...
