Thank you.
Mr. Chair, ladies and gentlemen, members of the committee, dear colleagues, I am very happy to be participating in this committee's work on LGBTQ+ health. I want to congratulate you on this work of collaboration and consultation.
Before I begin my remarks, allow me to introduce myself quickly.
First, on a personal level, I am a gay and cisgender man. On a professional level, as it is in that capacity I am participating in the committee's work, I am a sociologist, a member of the Centre de recherche de Montréal sur les inégalités sociales et les discriminations—CREMIS—where I coordinate the activities of a working group on gender and sexual diversity. I am also a planning and research officer at the Montreal regional public health directorate.
My professional and scientific expertise mainly focuses on gay and bisexual men, and other men who have sexual relations with men, be they cisgender or transgender. To shorten this, I will use the acronym gbMSM. I am interested in those men's conditions and situations mainly in the urban context. So I will speak today based on that expertise.
As an introduction to my presentation, I would like to specify the theoretical framework of my remarks—analysis relative to social inequalities in health. That analysis makes it possible to simultaneously look at systemic dimensions and community and individual realities of social health determinants. When we consider LGBTQ+ health, the analysis relative to social inequalities highlights the importance of a holistic health approach, in order to understand why sexually and gender diverse individuals are structurally in poorer health than the general population in terms of physical health, mental health, or in terms of the prevalence of blood borne and sexually transmitted infections, or STBBIs.
In the remainder of my presentation, I will identify the various health barriers faced by LGBTQ+ individuals as they appear both in scientific literature and in my professional practice.
In Quebec, LGBTQ+ health difficulties are documented inconsistently. For MSM, there are numerous studies, both quantitative and qualitative, mainly related to the HIV/AIDS epidemic. However, for lesbians, bisexuals, trans individuals and other sexually diverse people, the data is unfortunately more limited, often less specific, and mostly comes from what community organizations have been noting on the ground. However, there is sufficient retrospective to identify a few useful pieces of information on the various barriers LGBTQ+ individuals face in the recognition of their health problems.
My first point focuses on systemic or structural barriers.
In Canada, as in a number of developed countries, LGBTQ+ individuals have practically obtained equal consideration before the law. I say “practically”, as some rights are yet to be obtained, especially for trans individuals in Quebec. However, legal equality is not true equality. In other words, recognition of same sex couples and implementation of anti-homophobia policies are indisputable achievements, but they are often offside with the experience of many LGBTQ+ individuals.
In a society where heterosexuality remains the prevailing social norm, the experience and development of young LGBTQ+ people in particular remain strongly steeped in feelings of shame and, unfortunately, in name calling, bullying and violence. Those dimensions, which profoundly affect self-esteem, in large part explain the high rate of suicide attempts among LGBTQ+ individuals, but also more broadly the high prevalence of mental health issues, including anxiety, ill-being and poor body image. Saying this is not an acknowledgment of powerlessness. Our societies are evolving and can still evolve thanks to increased visibility of sexual diversity and gender and the proliferation of positive models, but also thanks to the work of allies and innovation in education.
My second point concerns barriers to LGBTQ+ health in the health system.
Over the past few years, a great deal of progress and innovation has been achieved, most often in response to the urgency of the AIDS epidemic. These advances are a very important source of education. However, they have two main limitations.
First, the existing services generally confine the health of sexual minorities to sexual health or the fight against STBBIs. Second, those services are first and foremost all adapted, with a few exceptions, to gay and bisexual individuals and other cisgender MSM.
However, the health problems of LGBTQ+ individuals largely stem from their difficulties to be recognized and welcomed in the health system as people with specific challenges and needs. That is a more obvious reality for LBTQ individuals than for gbMSM. The health care system, specifically in Quebec, is still all too often struggling to adapt to that reality for the following reasons.
First, the population in question is often perceived as a very small minority by the decision makers. That may be true in certain contexts, but it does not preclude the implementation of inclusive approaches and policies. Second, the health care needs expressed by LGBTQ+ communities unfortunately do not appear to always be a priority in the context of fiscal restraints. Finally, health authorities do not always have an adequate perception of health needs. In the absence of studies and available data, as I was saying in my introduction, certain segments of the population are unfortunately still being ignored. However, experience shows, specifically in Montreal, that service adaptation can be the focus of close cooperation between the affected communities, the organizations that represent them and health services.
The third level of barriers to LGBT health I wanted to talk about today stems directly from the precedent, as it concerns professional practices.
All too often, LGBTQ+ people ask for health services, but they are struggling with difficulties or going through negative or arbitrary experiences. Those difficulties can manifest in a number of ways.
First, there are discriminatory or stigmatizing practices, which unfortunately still exist. Second, health stakeholders or professionals, feeling insufficiently trained, refer patients to other colleagues, and that sometimes leads to unjustified wait times. Finally, more generally, it is difficult to reach a health care professional who is open and welcoming, either for reasons of geographic remoteness or financial barriers, or because those professionals are already overbooked.
The last barrier level I want to talk about has to do with the individuals themselves. Taking care of ourselves and our health is an eminently social and cultural practice. Gender and sexual orientation, but also skin colour, education level, income level and community integration play key roles in all those processes. Why? Because becoming aware that we have particular and legitimate health needs as LGBTQ+ individuals requires a certain level of personal comfort, a knowledge of our body, an ability to reason and a desire to take care of ourselves that also develop through interactions with other members of our community and with the health care system. The transition from a perceived health care need to the effective use of health care is part of the relationship map in the same way as care maintenance, pursuit of our treatment or medical follow-up.
Having provided a brief overview of these different barriers, I would like to conclude my presentation by identifying a number of potential solutions that stem mainly from my professional experience. From the outset, I want to specify that the success of these solutions is based on three winning conditions: intersectoral collaboration, recognition of the expertise of the affected communities, and the taking into account of diversity of health care needs of LGBTQ+ individuals.
The first potential improvement has to do with the health journey.
The first challenge related to the health journey is related to navigation. In Montreal, research with gbMSM has shown that, beyond specialized or adapted services, the key is also in the affected men's ability to navigate the health care system. Access to regular STBBI screening is a good thing, but that gateway should also make it possible to be referred, if necessary, to mental health services and addiction services, or community resources to break down isolation. The silo approach still conditions the use of care too often. Putting in place navigation tools, such as online service mapping, would make life easier for affected individuals and facilitate the work of health care professionals.
The second challenge related to the health journey is that health care needs of LGBTQ+ community members vary depending on identities and life stages. For example, LGBTQ+ seniors need services as seniors, but also as LGBTQ+ individuals. An integrated approach would help take that into account accordingly.
Finally, a third very simple idea to facilitate the health journey would be to implement visual tools such as posters or pamphlets in services or organizations indicating that LGBTQ+ individuals are welcome. Those signs of consideration, often discrete, are a favourable signal for the affected people to feel comfortable opening up to their health care professional.
The second potential improvement has to do more directly with health care professionals. It clearly concerns knowledge—so initial and ongoing training—as numerous tools now exist to develop the skills of professionals who deal with LGBTQ+ patients. It also has to do with know-how, as, contrary to a preconceived notion, it is not necessary to be an LGBTQ+ health care specialist to take on patients from those communities.
In most situations, availability and attention to the individuals can be enough to identify difficulties and consider health options or a direction to take. A patient disclosing their sexual orientation or their gender identity must be seen as a very significant step by health care professionals.