Madam Chair and members of the standing committee, good afternoon. Thank you for this opportunity to present to you on LGBTQ2 health. I commend you on taking this important step in conducting the first study on LGBTQ2 health in Canada.
I'm a social worker with more than a decade of front-line experience in community-based mental health, including providing counselling services to members of Toronto's LGBTQ2 communities. I've also participated in LGBTQ2 grassroots networks in Toronto as a member of the Rainbow Health Network, working collaboratively with my volunteer colleagues to begin to imagine what has now been realized as Rainbow Health Ontario.
Over the last decade or so, I have been an associate professor and director at the school of social work at York University and, more recently, at Renison University College, affiliated with the University of Waterloo. My academic research program has explored health services access and equity, with a particular focus on the implications of institutional policies and practices on high-quality equitable health care for diversely situated LGBTQ2 people. I'm a lesbian/queer cisgender woman.
I have listened to the presentations of witnesses who presented at previous meetings of the standing committee, and I commend my respected colleagues for offering critical accounts of health disparities experienced by LGBTQ people, underscoring the impact of homophobia and transphobia on mental health, highlighting the need to attend to the determinants of health and experiences of discrimination and stigma in health care encounters at the intersections of sexual orientation and gender identity and race, socio-economic status and aging, among other intersections, and finally, for calling for robust structures and methods for collecting Canadian data on LGBTQ2 health inequalities.
Today, I want to focus my remarks and recommendations on the issue of access and equity in health care services. In doing so, I underline one key point and related recommendations that I believe will serve to create change and promote access to high-quality care for LGBTQ2 people. This key point is education and training in health professional programs. To emphasize these points, I draw on experiences of participants from a CIHR-funded, Ontario-based research project on home care access for LGBTQ2 people, of which I was the principal investigator.
Research conducted in Canada, the United States and the United Kingdom has documented barriers to health services that limit access to good-quality care for diversely situated LGBTQ2 people. Health services access barriers include heteronormative practices and policies, including assessment and intake forms that fail to include same-sex relationship status options and that rely on the male-female gender binary. More generally, institutionalized heterosexism, biphobia, transphobia and lack of provider knowledge related to LGBTQ2 health needs and health service experiences have been implicated in the delay of preventative care, the failure to return for follow-up appointments and a general reluctance to report health issues for LGBTQ2 communities.
For example, Trans PULSE reported that 21% of trans participants in their study avoided emergency department care because of fear the encounter would be negative because of their trans status. A participant in the LGBTQ home care access project stated, “I know some folks who’ve had bottom surgeries, who have had friends and family and partners do all that work even if they’ve had fistulas or any kind of infections because they’re terrified”. They didn't want home care to come into their homes.
In response to access barriers, academic and community-based researchers and LGBTQ2 activists, organizations and allies have underscored the need for health provider education and training on the unique health and service experiences of sexual and gender minorities. Such calls for education and training initiatives are focused on providers in hospitals, long-term care and public health sectors. Similarly, literature on the LGBTQ2 learning needs of service providers has addressed health-related professional education programs, such as medicine, nursing and social work.
A review of the literature suggests that education and training initiatives are often conceptualized within a cultural competency framework and delivered in workshop formats ranging from one to six hours, while incorporating different learning components, including small discussion groups, written materials, LGBTQ2-identified speakers and videos. They often include topics such as LGBTQ2-related terminology and concepts, information on barriers to health services and health disparities, and sector-, service- or illness-related information—for example, on aging and long-term care, palliative care, HIV, youth and mental health.
While there appears to be variability in terms of access to education across regulated health professional groups, overall access to repeated opportunities that offer both breadth and depth in terms of LGBTQ2 health and health service access experiences are extremely limited. Repeated opportunities for education and training are crucial. It is not simply a matter of acquiring knowledge, but rather is most often a matter of doing the difficult work of shifting discriminatory beliefs and attitudes, fear and apprehension.
A service user in the LGBTQ2 home care access project described her home care provider's reaction to learning that she was a lesbian and married to a woman. She said, “I was sitting here and [the home care worker] was there and she backed up and, '*Gasp* never heard of that!'.” She had never heard of a lesbian. “She didn't say a lot in words, but her body language was very judgmental. She stepped back and sort of put her hands up and then she was very careful not to touch me.”
From this point, I offer the following recommendations for federal, provincial and territorial governments to consider with respect to mental health care provider education and training.
Recommendation one is for sufficient funding formulas that adequately provide resources for comprehensive health professional programs.
At a policy level, ministries responsible for both education and health must work collaboratively to consider funding formulas that adequately provide resources for comprehensive health professional programs that prepare health professionals to respond to the diverse and complex health needs and health service experiences of sexual and gender minority service users. This includes resources to fund curricula development in health professional programs that not only address clinical knowledge unique to LGBTQ2 people, but also educational approaches that foster transformative learning, shifting deeply held discriminatory beliefs and attitudes toward LGBTQ2 people.
In the absence of comprehensive health professional programs, LGBTQ2 people are too often put in the position of needing to educate their health care providers, all the while contending with acute, chronic and/or life-threatening illnesses. A participant in the home care project graciously said, “I had to educate, and they actually appreciated the education because they didn't really have much experience with transgender people. They didn't understand what it meant, so I had to explain it.”
Recommendation two is on accreditation standards for post-secondary health professional programs.
A systematic review of accreditation standards for all health professional programs through their respective national accrediting bodies is needed to identify gaps in accreditation standards that are specific to LGBTQ2 communities, and then associated standards need to be developed. Ensuring that the curricula of health professional programs include information related to LGBTQ2 communities seems especially important, given the paucity of content in these programs and the paucity of continuing education opportunities once health professionals are in the field.
In the home care project, out of 379 health care providers we surveyed, only 47 had access to LGBTQ2-specific education. Of that 47, 50% attended a half-day workshop. The other 50% attended a workshop that was one to two hours long. Once they were employed in the health care sector, 90% had never received LGBTQ2-focused education.
I'm going to skip recommendation three and go to recommendation four, which is on education and training opportunities for unregulated health providers.
Personal support workers increasingly are providing the bulk of health care to service users. In the home care project, they indicated they have had no opportunities for LGBTQ2 education and training in their training programs or since they had been employed in the home care sector. They have other training opportunities, but not related to LGBTQ2.
My fifth recommendation is a federal accountability structure. There must be an accountability structure to provide oversight and direction for the recommendations identified above. The creation of an accountability structure at the federal level would be well aligned with the Government of Canada's commitment to advocating for the protection and promotion of the human rights of lesbian, gay, bisexual, transgender and intersex persons globally.
Notwithstanding this commitment, it may be that it is more appropriate or feasible to think about accountability structures at the provincial and territorial levels, given their responsibilities for education and health.
Thank you.