Health Inequalities Among Sexual and Gender Minorities in Canada: Current Data and Evidence for Promising Interventions

January 16th, 2020
Ottawa, Canada

The Canadian Institutes of Health Research (CIHR) and the Public Health Agency of Canada in collaboration with the Centre for Gender, Diversity and Inclusion Statistics, Statistics Canada, the LGBTQ2 Secretariat at the Privy Council Office, Women and Gender Equality Canada, and the Institute of Gender & Health, CIHR

Objectives

Given that the drivers of health inequalities for sexual and gender minorities (SGM) in Canada fall under multiple departmental jurisdictions, this BBE aimed to bring together policy actors from multiple departments with researchers to engage in a focused dialogue on knowledge, challenges and opportunities for coordinated action and facilitate a cross-department coordination and/or collaboration approach in addressing health equity for SGM in Canada. For policy leaders, this was an opportunity to generate a shared understanding of data, research and policy priorities for SGM Canadians that is informed by the best available research evidence. The Public Health Agency of Canada was particularly interested in interventions that address mental health and resilience, healthy living, and stigma awareness and reduction among SGM Canadians to inform policy and programming priorities.

More specifically, the BBE allowed participants to:

  1. Review current evidence and identify knowledge gaps on the key inequalities in health and the social determinants of health experienced by SGM populations in Canada, in order to support targeted policy and program development, including evidence from community-driven assessments of programming needs.
  2. Identify and share evidence of promising practices, and interventions with demonstrated impact in promoting health and reducing health inequalities among diverse SGM populations.
  3. Support the design, implementation, and evaluation of future interventions to better address the needs of SGM populations.
  4. Leverage the opportunity to share information, dialogue, and strengthen relationships in support of coordinated action on health inequalities for SGM populations.

Background and Policy Context

Addressing and monitoring progress on health inequalities among sexual and gender minorities (SGM) in Canada, which are rooted in experiences of stigma and discrimination, are key priorities for the Public Health Agency of Canada (PHAC). This issue is relevant to the Government of Canada’s commitment to advance LGBTQ2 inclusion and improve equality for LGBTQ2 communities through the promotion of human rights and the development of inclusive federal policies, programs and laws.

This issue is also relevant to PHAC commitments to health inequalities reporting, measuring and monitoring health inequalities, and activities related to sex and gender-based analysis plus (SGBA+), the social determinants of health, and health equity. PHAC has adopted a broad approach to SGM health, which considers social determinants of health, health behaviours and a broad range of health outcomes, including chronic diseases, mental health, and sexually transmitted and blood-borne infections (STBBI).

This event supported PHAC's commitment to measure, monitor and strengthen health equity, and contribute to the development of coordinated action to address health inequalities for SGM populations.

This BBE focused on reviewing current evidence, identifying key data needs, and finding opportunities to strengthen interventions to improve health equity for SGM populations. The discussions will inform a number of PHAC initiatives; in particular, the Health Inequalities Reporting Initiative and PHAC’s community based programs in the areas of healthy living, mental health, early childhood development, sexually transmitted and blood-borne infections (STBBI), and gender-based violence. The Health Inequalities Reporting Initiative undertakes ongoing monitoring and reporting on the state of health inequalities in Canada and represents the most comprehensive pan-Canadian data resource on health inequalities currently available.

Need for Evidence

This BBE was timely given the recently published Report of the House of Commons Standing Committee on Health on “The Health of LGBTQIA2 Communities in Canada” (June 2019). In particular, several recommendations call for interventions to address the health of LGBTQIA2 communities, which include addressing stigma and discrimination, and improving the data infrastructure to better monitor the health inequalities experienced by SGM in Canada. This BBE event will support PHAC in mobilizing the most recent research and evidence to support action on the Committee’s recommendations, and strengthen our ongoing work to measure, monitor, and reduce health inequalities for SGM Canadians.

Access to timely, relevant and high-quality evidence will position PHAC and its partners to support and develop data, research, programming, and policy that responds to the needs of SGM. In particular, the BBE will inform PHAC’s work in surveillance, research, community-based programming and policy development. It will also support the development of PHAC’s training and capacity building initiatives related to evidence and practice for SGM populations for public health professionals within PHAC.

Anticipated Outcomes

The BBE will help strengthen efforts across the Government of Canada to build knowledge and mobilize action on key inequalities in health and the social determinants of health for SGM in Canada. Coordinated action with other government departments and units to address these data and evidence gaps will help facilitate targeted and/or adapted policy and program development, and will help build PHAC’s capacity to address this issue.

Anticipated outcomes of this event include:

  1. An improved understanding among policy-leaders of evidence-informed priorities for data, research, and action on the determinants of health inequities for SGM Canadians.
  2. Improved engagement across departments to support coordinated action on these priorities in the medium-term.
  3. Improved communication among experts within and outside of government to strengthen and share data and evidence related to SGM in Canada, and their health and social outcomes, to better inform policy and programming.

PHAC will use the information shared and relationships strengthened through the BBE to continue to build the evidence base for SGM populations. PHAC will also use the outcomes and recommendations from the BBE to inform the design, implementation, and evaluation of its relevant community based programs and policy development to be more inclusive and to better meet the needs of SGM populations. PHAC and other government departments will work with partners within and outside the health sector, including with provinces and territories, and other federal government departments, to advance priority initiatives following the BBE.

Presentation Summaries

The BBE was facilitated by Cara Tannenbaum, Scientific Director, Institute of Gender and Health, Canadian Institutes of Health Research & Departmental Science Advisor Health Canada and Devon MacFarlane an Independent Consultant. Here is a summary of the evidence presented by each of the presenters:

Health Inequalities Among Sexual & Gender Minorities (SGM) in Canada: Current Data & Evidence for Promising Interventions

Jacqueline Gahagan, Professor of Health Promotion, School of Health and Human Performance, Faculty of Health Professions, Dalhousie University

There are long-standing system-level inequalities that impact on the health and wellness of sexual and gender minorities (e.g. lesbian, gay, bisexual, transgender and other gender non-conforming populations). Dr. Jacqueline Gahagan described how the historical focus on homosexuality as a mental disorder has failed to fully recognize the ways in which system-level drivers (e.g. health, education, legal) impact on the health and social outcomes of SGM populations. As such, there is very limited data on the factors that contribute to health and resilience across the life course among SGM Canadians. Data collected using heteronormative research approaches, framing and language cannot be extrapolated to SGM populations. Rather, we need to rethink the measures and methods needed to better understand resilience and wellness within SGM populations at both the systems- and population-levels.

Surveys and Sexual Orientation Genderplay and Resilience

Fenton Litwiller, Assistant Professor, Faculty of Kinesiology and Recreation Management, University of Manitoba

This presentation outlined two of Dr. Fenton Litwiller’s current research projects. The first, ‘Surveys and Sexual Orientation’, is concerned with developing a survey question that accurately represents the lived experience of sexual orientation for both queer and straight communities. I articulated current research measuring sexual orientation and gender identity (SOGI), identified challenges with this work, and outlined future directions. The second, ‘Genderplay and Resilience’, uses a drag performance and genderplay workshop (make up, costuming, and movement to music facilitated by mentors) to study gender identity, gender expression and resilience with 2SLGBTQ youth using participatory action research, interviews, and observation. Preliminary results from this study indicate that community based genderplay programs facilitate individual, relational, and cultural/community resilience and positive mental health. These workshops were fun, spontaneous, and creative spaces for youth to explore multiple aspects of themselves and, in some cases, allowed them to be someone that they could not at home. The workshop facilitated social assets and resources through new friendships with peers, trained adult mentors, and queer organizations. It was also a space for youth to talk about the concerns in their lives. In this context, youth learned about the possibilities for gender while feeling a part of something larger than themselves (queer community).

Promoting healthy living among SGM Canadians – Promising practices and intervention research

Nathan Lachowsky, Research Director Community Based Research Centre for Gay Men’s Health; Assistant Professor, University of Victoria

Community-based approaches to research, knowledge translation, network building, leadership development, and intervention are a promising approach to advance LGBTQ2+ health. We conducted a rapid environmental scan of programs and interventions promoting health equity among LGBTQ2+ populations in Canada through action on social determinants of health. Over 200 programs were identified and reviewed, identifying gaps based on geography, targeted sub-communities, and social determinants of health addressed. Most programs focused on the individual or interpersonal level with few interventions operating at a structural level. Common principles or approaches identified through the scan were harm reduction, providing safe environments, social justice, anti-oppressive practices, values-based approaches, system navigation, and enhancing social competence and allyship. The approach, project and initiatives of the national Community Based Research Centre (CBRC) were highlighted as a promising case study of strategy to improve LGBTQ2+ health in Canada. The CBRC’s Sex Now survey has routinely collected policy-relevant data such as the perceived discrimination and support for alternatives to blood donor deferral of men who have sex with men. The CBRC’s Totally Outright youth leadership program has expanded across Canada; research demonstrates how these empowerment programs ameliorate HIV-related inequities. Finally, systems change efforts related to LGBTQ2-relevant data infrastructure and practices are needed in order to support rigorous evaluation of policy and program impact. Recommendations are to require community- and peer-based approaches, strengthen LGBTQ2+ networks, integrate LGBTQ2-relevant social determinants (e.g. social norms, adverse childhood experiences), scale leadership programs, address knowledge gaps through community-based research, revise stigmatizing policies and foster innovative knowledge translation.

Promoting Mental Health and Resilience among SGM Newcomers

Sarilee Kahn, Associate Professor, School of Social Work, McGill University

This presentation provided recommendations for supporting mental health for sexual and gender minority (SGM) newcomers in Canada. Based upon findings from 6 separate studies with service providers, mental health professionals, and/or SGM newcomers in Canada and other host countries, mental health risk factors pre-migration, during asylum-seeking and/or early resettlement were enumerated. Pre-migration traumatic events reported involved physical, sexual, and emotional abuse from childhood onward; perpetrators could be family members, religious leaders, teachers, peers, police, and/or government officials. Mental health symptoms such as PTSD, complex PTSD, depression, and suicidality were reported. Immediately after migration and arrival, SGM newcomers seeking asylum could encounter additional mental health risks related to the requirement to “come out” as a sexual or gender minority, and to disclose past traumatic events, while struggling to adapt and survive. Additional mental health risk factors involved discrimination-based barriers to establishing social and economic capital in the destination country based upon multiple marginal identities. Recommendations included ongoing trauma-informed/SGM-affirmative training for immigration officials, immigration attorneys, and settlement workers; strengthening linkages between ‘mainstream’ health/mental health providers and grass-roots organizations serving SGM newcomers – and increasing funding for such organizations; supporting group therapy and peer support groups, particularly in less-populated locales; encouraging programmes that promote found families and HIV education/prevention; and establishing and sustaining coalitions among policy makers, mental health providers, attorneys, local orgs, employers, housing advocates, and SGM newcomers themselves to create webs of psychosocial support – to help prevent chronic mental health problems, homelessness, joblessness, and HIV risk for this vulnerable, yet resilient, population.

Intersectionality and Black Queer Youth: Promising Practices & Implications

Lance McCready, Associate Professor, Department of Leadership, Higher and Adult Education, University of Toronto

Dr. Lance T. McCready presented an intersectional approach to promote the health and well-being of Black queer (LGBT2SQI) youth. The presentation was based on findings from Dr. McCready’s qualitative research on the educational trajectories of Black queer youth in Canada and the United States. Dr. McCready described his transition from research on gay and gender non-conforming students’ experiences in urban schools to education, health and well-being of Black queer youth in Canadian urban centres. He explained key concepts of an intersectional approach, including intersectionality, social determinants of health (SDOH) and engaged scholarship. Dr. McCready briefly described the qualitative research projects that used to formulate an intersectional approach: Making Space for Diverse Masculinities, Educational Trajectories of Black Queer Youth and Black CAP Adaptation of 3MV. Overall,  the findings from these research projects suggest that:

  1. Canada’s urban centres are a more diverse group than they were a decade ago; there are more LGBTQ youth from newcomer, English language learner, non-White, low-income backgrounds than ever before.
  2. Rural, poor, newcomer, indigenous and visible minority LGBTQ youth at-risk for being isolated from mainstream programs and services because they:
    1. do not identify as sexual minorities in mainstream ways
    2. are unaware of and/or live far from programs and services for LGBTIQ youth.

Based on these findings,four principles of an intersectional approach were outlined.

  1. Conceptualize LGBTQ youth as a heterogeneous population
  2. Collect data on multiple SDOH
  3. Conduct analyses that aim to compare outcomes across different ethnoracial populations as well as within particular ethnoracial populations
  4. Develop curriculum, programs and interventions that speak to multiple identities and SDOH.

A key implication of an intersectional approach is developing anti-oppressive approaches to policymaking, research and practice that address multiple SDOH and their intersections, and challenge the “commonsense” of what it means to do health promotion work with LGBTQ youth in Ontario.

What the Unexpected Tells Us About Health Policy

Margaret Robinson, Assistant Professor, Department of Sociology and Social Anthropology Dalhousie University

Dr. Margaret Robinson of Dalhousie University presented lessons learned from unexpected health research results. Common assumptions lead most of us to expect particular research results. When it comes to cannabis use, for example, we usually expect that straight people will have a relatively low level of cannabis use, while gays and lesbians, who experience homophobic oppression, will have a higher rate of use. We may expect bisexuals to fall somewhere between these two extremes. Instead those in the middle—in this case bisexuals—have the highest rates of cannabis use, as indicated by population-based studies in a number of countries, including Canada. Similarly, LGBTQ poverty is under-researched due to stereotypes portraying gay men as wealthy. Despite this stereotype, bisexual people are over-represented in the lowest income quintiles, and partnered gay men earn less than straight men. Lumping sexual minority groups together hides disparities within these populations. When we lump similar groups together we can also miss important successes. If suicide rates for Aboriginal people are compared to those of settlers, for example, we see an enormous disparity, but no explanation or suggestions for improvement. However, if Aboriginal suicide rates are separated by Indigenous community, as Chandler, Lalonde, and Hallett did with data from British Columbia, we see a very different picture. Communities with a strong Indigenous culture had low or no suicide. By attending to the hidden diversity within groups we may find solutions in what previously showed only problems.

Recommended Readings

  1. Community Based Research Centre. (March, 2019). DRAFT Environmental Scan: Programs and Interventions Promoting Health Equity Among LGBTQ2S Populations in Canada Through Action on Social Determinants of Health.
  2. Kahn, S., Alessi, E., Woolner, L., Kim, H., & Olivieri, C. (2017). Promoting the wellbeing of lesbian, gay, bisexual and transgender forced migrants in Canada: providers’ perspectives. Culture, health & sexuality, 19(10), 1165-1179.
  3. Kia, H., Robinson, M., MacKay, J., & Ross, L. E. (2019). Poverty in lesbian, gay, bisexual, transgender, queer, and two-spirit (LGBTQ2S+) populations in Canada: an intersectional review of the literature. Journal of Poverty and Social Justice.
  4. McCready, L. (2015, October). A double life: Black queer youth coming of age in divided cities. In The Educational Forum (Vol. 79, No. 4, pp. 353-358). Routledge
  5. Ross, L., Kia, H., & Khanna, A. (2018). Monitoring Poverty in the LGBTQ2S+ communities: Recommendations for Canada’s Poverty Reduction Strategy. Canadian Coalition Against LGBTQ2S+.
  6. Warner, L. R., & Shields, S. A. (2013). The intersections of sexuality, gender, and race: Identity research at the crossroads. Sex roles, 68(11-12), 803-810.

Online References:

  1. Community-Based Research Centre. Projects + Initiatives.
  2. Cotter, A. and Savage, L. (2019). Perceptions related to gender-based violence, gender equality, and gender expression.
  3. Fredriksen-Goldsen, K. I., & Kim, H. J. (2017). The science of conducting research with LGBT older adults-an introduction to aging with pride: National health, aging, and sexuality/gender study (NHAS).
  4. Gilmour H. Sexual orientation and complete mental health. Health reports. 2019 Nov 1;30(11):3-10.
  5. Hunt, S. (2016). An introduction to the health of two-spirit people: Historical, contemporary and emergent issues. [ PDF (4.27 MB) - external link ]. Prince George, BC: National Collaborating Centre for Aboriginal Health.
  6. Kahn, S., & Alessi, E. J. (2017). Coming out under the gun: Exploring the psychological dimensions of seeking refugee status for LGBT claimants in Canada. Journal of Refugee Studies, 31(1), 22-41.
  7. McCready, L. (2017). Black Queer Youth, Unstable Housing and Homelessness: Understanding the Impact of Family Conflict, School and Community-Based Violence on Racialized LGBTQ2S Youth [ PDF (239 KB) - external link ]. Canadian Observatory on Homelessness.
  8. Pan-Canadian Health Inequalities Data Tool, 2017 Edition. A joint initiative of the Public Health Agency of Canada, the Pan-Canadian Public Health Network, Statistics Canada and the Canadian Institute of Health Information.
  9. Public Health Agency of Canada. (2018). Reducing the health impact of sexually transmitted and blood-borne infections in Canada by 2030: A pan-Canadian STBBI framework for action.
  10. Rainbow Health Ontario. (2019). The Health Equity Impact Assessment Tool (HEIA): LGBT2SQ Populations Supplement [ PDF (547 KB) - external link ].
  11. Tam, T. (2019). Addressing Stigma: Towards a More Inclusive Health System — Chief Public Health Officer of Canada’s 2019 Annual Report.
  12. Women and Gender Equality Canada. Government of Canada Invests in LGBTQ2 Communities in Québec. (2019).
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