A–Z OF PUBLIC HEALTH

lesbian, gay, bisexual and transgender

SEE ALSO gender mainstreaming; inequalities agenda; men’s health; prostitution; social movements; violence; women’s health

Lesbian, gay, bisexual, and transgender (LGBT) is intended to emphasize a diversity of sexuality and gender identity-based cultures and refers to anyone who is non-heterosexual or non-cisgender and not exclusively to people who are lesbian, gay, bisexual, or transgender (Swain, 2007).

LGBT, though not a universally accepted term, does refer to individuals who are often a vulnerable and marginalized segment of the population due to the discrimination that members often experience. The portrayal of an inclusive LGBT community is resisted by some lesbian, gay, bisexual and transgender people because the term implies a solidarity that does not exist. By grouping LGBT people together perpetuates the myth that being gay/lesbian/bi makes a person deficiently different from other people and assumes all LGBT people support liberation, which may not necessarily be a shared point of view (WHO, 2013d).

LGBT persons experience higher rates of depression, anxiety, tobacco use, alcohol abuse, homelessness, suicide and disconnectedness from a range of health and support services. Gay men and transgender individuals are also at a higher risk of HIV and viral hepatitis and have higher rates of mental health issues (Global Health, 2014).

Homosexuality is criminalized in more than 70 countries in which there can be severe implications for the health and well-being of the LGBT community because failing to engage with gay people can exclude them from preventive interventions in the population (WHO, 2013d). One of the most prominent explanatory frameworks of sexual minority health risk is the minority stress model. Minority stress theory proposes that sexual minority health disparities can be explained in large part by stressors induced by a hostile, homophobic culture which results from harassment, maltreatment, discrimination and victimization and may ultimately impact access to health and social care. Many of these stressors overlap, representing their interdependency and confounding effect within society. Stressors such as homophobia or sexual stigma require an individual to adapt which in turn can cause more stress and affects physical and mental health outcomes (Meyer, 2003).

Stigma and discrimination against LGBTs in the health sector can also prevent access to needed health services, as well as a lack of respect and the denial of treatment. Issues related to patient confidentiality, while important to all patients, may be particularly important to LGBT people who have not yet disclosed their sexual orientation and/or gender identity. Other barriers to care for LGBT people include abuse, restrictions against treatment, inappropriate assumptions about the causes of health, avoidance of treatment and poor understanding on the part of health providers of the specific health care needs of LGBT persons (Barnett-Vanes, 2014).

The rapid development of gay men’s health stemmed in part from an increasingly influential health movement (Courtenay, 2011) including strong pressure from groups representing the rights of LGBT. ACT-UP was one of the first and most active pressure groups in regard to the AIDS epidemic that swept through the gay community in America. ACT-UP was formed in New York by a group outraged at the government’s mismanagement of the AIDS crisis. AIDS activism became an important component of the lives of LGBT people living with HIV/AIDS by helping them to identify and organize around issues that they felt were important. The primary mechanism of change for AIDS activists is intra-group and inter-group communication through networking involving active recruitment meetings, the mass media, encounters with allies and counter-movement groups. ACT-UP frequently met with government officials and industry leaders to debate changes in policy, and this gave the organization an unprecedented level of leverage and influence. One of ACT-UP’s major victories was changing drug testing and approval processes in the United States including expanding access to clinical trial participation, decreasing reliance on placebo-controlled drug trials and accelerating the drug-approval process (Brashers et al., 2002).

LGBT use a number of options to prevent HIV infection including pre-exposure prophylaxis or PrEP, which is a way for people who do not have HIV but who are at substantial risk of getting it to prevent it by taking a daily medication. When someone is exposed to HIV, PrEP can work to keep the virus from establishing a permanent infection. When taken consistently, PrEP has been shown to reduce the risk of HIV infection in people who are at high risk by up to 92%. PrEP is a powerful HIV prevention tool and can be combined with condoms and other prevention methods to provide even greater protection (CDC, 2014). In countries where preventive medication such as PrEP is not available condoms are the main method to prevent HIV infection. MPlus, for example, is a non-profit organization in Chiang-Mai, Thailand that serves the gay, lesbian, and transgender community. The work of this organization mainly involves engaging with men who have sex with men in parks where quick, anonymous and often rough sex takes place. The project provides condoms and safe-sex information and has established a drop-in centre and clinic where gay men can be tested and treated for STIs. The project also uses mobile and online technologies as well as a peer education approach that uses offline social networks (Walsh, 2011).

To achieve a better understanding of the health needs of LGBT persons more data is needed on the demographics of these populations, as well as improved methods for collecting and analysing data, involving civil society and faith-based organizations (Global Health, 2014).

KEY TEXTS

•Firth, L. (2012) LGBT Equality (Cambridge: Independence Educational Publishers)

•Levounis, P., Drescher, J. and Barber, M. (eds) (2012) The LGBT Casebook (Arlington, VA: Psychiatric Publishing)

•World Health Organization (2013d) ‘Addressing the Causes of Disparities in Health Service Access and Utilization for Lesbian, Gay, Bisexual and Trans (LGBT) Persons’. 52nd Directing Council. 65th Session of the Regional Committee. Concept Paper. Washington DC. 30 September 2013

lifestyle

A lifestyle is a way of living based on identifiable patterns of behaviour which can create a pattern of individual’ personal characteristics, social interactions and socioeconomic and environmental conditions (WHO, 1998).

Individual lifestyles, characterized by identifiable patterns of behaviour, can have a profound effect on health and on the health of others. Public health strategies often target physiological, behavioural or psychosocial lifestyle risk factors in regard to both non-communicable disease (physical inactivity, smoking, alcohol and drug abuse) and communicable disease (sexual activity, exposure to vectors and infectious agents). Injury prevention is also used as a strategy to prevent or reduce the severity of bodily injuries caused by patterns of behaviour or by unintentional, preventable risks.

If health is to be improved by enabling individuals to change their lifestyles, action must be directed not only at the individual but also at social and living conditions which interact to produce and maintain these patterns of behaviour. It is important to recognize that there is no optimal lifestyle to be prescribed for all people. Culture, income, family structure, age, physical ability, home and the work environment will make certain ways and conditions of living more attractive, feasible and appropriate to different individuals (WHO, 1998).

The lifestyle approach became increasingly important in the 1970s when public health programmes to prevent smoking, alcohol abuse and physical inactivity became popular. This was because it was generally accepted that an individual’s lifestyle could directly influence his or her health and that people could be educated to make informed choices so as to avoid these high-risk behaviours. The assumption was that changing knowledge would also lead to a change in a person’s attitude and practice. This placed an emphasis on individual responsibility for health and which inevitably led to a professional culture of victim blaming. Health is individualized by people who regard it as personal in nature and there can be a tendency to blame them for their ill health, as it is assumed that people are responsible for the things, both good and bad, that they do. However, overtime health professionals recognized that behaviour is not an isolated action under the autonomous control of the individual, but that health is strongly influenced and conditioned by a complex interplay of social, political and cultural factors; factors that are sometimes outside the control of the individual.

Two well-known lifestyle approaches in the United States were the Multiple Risk Factors Intervention Trial (MRFIT) and the Community Intervention Trials for Smoking Cessation (COMMIT). The MRFIT was a ten-year programme designed to reduce mortality from heart disease in the top 10% of male risk group. The trial undertook a massive survey of 400,000 men in 22 cities and randomly selected 6000 for the intervention and 6000 for the control group. The trial was the most ambitious, expensive and intensive anywhere tried at the time in 1971. The trial failed and after six years the men in the intervention group did not achieve a lower mortality level from coronary heart disease than men in the control group. The COMMIT consisted of nationwide studies involving over 10,000 heavy smokers in 11 cities with a matched control group. At the end of this trial there was only a modest difference in the rate of people stopping smoking between the intervention and control groups. The trial, which cost millions of dollars and used a team of highly motivated and trained ‘experts’ to implement, similarly failed (Syme, 1997).

An analysis of the modest degree of success of lifestyle programmes identified that motivation to change behaviour must come from the person and cannot come from an expert. Providing education to influence individual lifestyle remains an important strategy in many public health programmes. This must support the underlying social, economic and political issues that have been identified as being relevant and important to the person. The programme must also have an influence on the broader context in which they live, for example, through a supportive environment or policy (Syme, 1997).

KEY TEXTS

•Naidoo, J. and Wills, J. (2009) Foundations for Health Promotion. 3rd edn (Edinburgh: Bailliere and Tindall)

•World Health Organization (2002) ‘Reducing Risks, Promoting Healthy Life’. The World Health Report 2002 (Geneva: World Health Organization)

•World Health Organization (2013) Chronic Diseases and Health Promotion. Available at http://www.who.int/chp/en/. Accessed 21 January 2013