Sexual Diversity and Gender Identity
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1. Sexual Diversity in Society
1.1 Homosexuality is defined as the sexual and emotional attraction to members of the same sex, and has existed in most societies for as long as sexual beliefs and practices have been recorded. The proportion of the population that is not exclusively heterosexual has been estimated at between 8 and 11 percent.1 This figure will naturally vary depending on the definitions used to describe the continuum of sexual identity that exists in our society.
1.2 Societal attitudes towards homosexuality have had a decisive impact on the extent to which individuals have been able to express their sexual orientation. In 1973 the American Psychiatric Association removed homosexuality from the Diagnostic and Statistical Manual of Mental Disorders. Subsequently homosexuality was recognised as a form of sexual orientation or expression rather than a mental illness.2 This move by the medical professional was instrumental in improving the health and welfare of this population.
1.3 Strong family connections are important to the health and well being of individuals, and recently there has been greater recognition of the diversity of family structures that exist in our society. These family structures could include nuclear families, single parents, blended families from remarriages as well as gay and lesbian parents. Accurate statistics regarding the number of parents who are gay or lesbian is difficult to obtain, as this data is not routinely collected. However, the American Academy of Paediatrics states that ‘the weight of evidence gathered during several decades using diverse samples and methodologies is persuasive in demonstrating that there is no systematic difference between gay and nongay parents in emotional health, parenting skills, and attitudes towards parenting. No data have pointed to any risk to children as a result of growing up in a family with one or more gay parents.’3
2.1 The term “heterosexism” has been used to describe the discrimination against gay, lesbian, bisexual, transgender and intersex (GLBTI) populations. Heterosexism encompasses the belief that all people are and should be heterosexual and that alternative sexualities pose a threat to society. In this way heterosexism includes homophobia, a fear of alternative sexualities, and transphobia, a fear of alternative gender identities. It may also include a fear of intersex people who do not fit neatly into the binary categories of male and female.4
2.2 Discrimination may be overt as in verbal abuse and physical violence or as covert as the silence that surrounds talking about GLBTI issues. This affects all members of society as individuals comply with gender role stereotypes in order to avoid homophobic discrimination. It is a constraint on human behaviour that serves to diminish individual potential for development as well as diversity in our community.
2.3 The common experience of discrimination means that the health of GLBTI populations differs from that of the general population. This discrimination leads to health problems that are shared by this group as well as health problems specific to each subgroup. For GLBTI individuals the impact of this discrimination can lead to a poorer general health status, diminished utilisation of healthcare facilities5 and a decreased quality of health services.6
3. Shared Health Issues
3.1 Society’s acceptance of diverse sexualities and gender identities is a major factor in an individual’s successful transition through various lifestages. These significant lifestages include childhood, youth, middle age and ageing. As GLBTI people transition through these lifestages there are a number of health issues that are commonly faced.
3.2 Mental health problems are statistically over-represented in this population throughout life due to exposure to discriminatory behaviour.7,8 One of the main groups affected by homophobia is same-sex attracted young people, particularly those living in rural areas where there is greater social isolation from GLBTI peers and role models. A consequence of this discrimination for GLBTI young people is that they have increased rates of homelessness, risk-taking behaviour, depression, suicide and episodes of self-harm compared to their heterosexual cohorts.9
3.3 The experience of violence is higher for the GLBTI community than the general population10 and a recent survey of the GLBTI community in Victoria indicated that “over 70% of respondents had been subject to an experience of public abuse in the past 5 years”.11 This experience may range from verbal abuse to physical attack. The experience or threat of violence has the potential to have a significant impact on an individual’s physical and mental health.
3.4 Patterns of drug and alcohol use within the GLBTI community are greater that that of the general population. The increased incidence of smoking and alcohol intake is also of concern in relation to cardiovascular risk factors. There is support for the theory linking individual patterns of drug and alcohol misuse with experiences of discrimination.12
3.5 Australia’s Aged Care policies make no reference to the specific needs of GLBTI older people, particularly in relation to institutional care. There is a need to recognise sexual and gender diversity within the aged care sector as this lack of recognition means that the health needs of many older people are not being adequately addressed with culturally appropriate care.
4. Specific Health Issues
4.1 Lesbian women
4.1.1 Lesbian women have been found to access breast and cervical screenings less regularly13 than recommended and lack awareness of the risk of sexually transmissible infections (STI). STIs are also a risk for women if they are prevented from accessing appropriate insemination services and lack medical support to assist in screening known sperm donors.
4.2 Gay men
4.2.1 Epidemiological studies in Australia have found gay men to be at high risk of contacting HIV/AIDS and other STIs. There is also an increased risk of both hepatitis A and B in this population. Research indicates that gay men are at greater risk of anal cancers and intestinal infections compared to their heterosexual cohorts.14
4.3 Bisexual people
4.3.1 Recent studies have reported Bisexual people to have worse mental health than their homosexual or heterosexual counterparts due to more adverse life events and less positive support from family and friends15. Bisexual people may also be at greater risk of STIs due to a lack of targeted health promotion activities.16
4.4 Transgender people
4.4.1 Transgender people are amongst the most marginalised and discriminated against groups in our society. Transgender people experience a high rate of depression and suicidal ideation.17 Transgender people may be medically dependent due to the need for ongoing hormonal treatment or possible surgical intervention. These can lead to specific physical health problems.
4.5 Intersex people
4.5.1 There is little published research on the Intersex population in Australia however anecdotal research indicates that experiences or expectations of discriminatory treatment may lead to decreased accessing of healthcare facilities. This has flow on effects for untreated mental and physical health problems.
5. Medical Profession
5.1 Medical practitioners have a high status in society and their views carry much authority. They therefore have a role to play in promoting acceptance of sexual and gender diversity. For many people their only contact with health professionals is with their family doctor and as such they are often the first person an individual talks to about their sexuality or gender identity. A doctor’s assumptions regarding sexual orientation, or the patient’s reluctance to disclose his or her sexual orientation and behaviour can lead to failure to screen, diagnose, or treat important medical problems.
5.2 GLBTI people are also represented amongst health professionals, who can also experience issues of discrimination and heterosexism within their own profession. These attitudes can have a negative impact on career satisfaction and progression.
6. The AMA Position
6.1 The AMA believes that a doctor’s non-judgmental acknowledgment of a patient’s sexual orientation, gender identity and behaviour enhances clinical care.
6.2 The AMA reaffirms its belief in equity of access to health care for all Australians.
6.3 The AMA acknowledges that a doctor’s use of language that assumes an individual to be heterosexual makes it harder for a person to disclose their sexuality.
6.4 The AMA is supportive of interventions that prevent the development of homophobia, as this will improve the health of all Australians.
6.5 The AMA recognises medicine is a diverse profession and is supportive of equal opportunity policies, which stress that GLBTI people receive the same protection as others in areas such as recruitment, promotion, training, transfer, terms and conditions of service and dismissal.
6.6 The AMA is supportive of legislation that proscribes discrimination and provides legislative recognition of same-sex unions and families as this will lead to legal, societal, financial and healthcare equity within the community.
6.7 The AMA believes that medical education curriculum should include subjects addressing issues of sexuality and gender identity. This should include information on the coming out process, education regarding discrimination, health needs of GLBTI subgroups and information about referral networks. This should start in medical school and be a part of continuing medical education at all levels.
6.8 The AMA believes that acknowledgment of same-sex partners is important in medical decision making and that these partners should be afforded the same next of kin status as their heterosexual counterparts.
6.9 The AMA is supportive of research and education that addresses the specific health needs of the GLBTI population.
6.10 The AMA opposes the use of “reparative” or “conversion” therapy that is based upon the assumption that homosexuality is a mental disorder and that the patient should change his or her sexual orientation.
7. Glossary of terms
Gay : A man whose primary sexual and emotional attraction is to towards other men.
Lesbian : A woman whose primary sexual and emotional attraction is to towards other women.
Bisexual : A man or woman who is sexually and emotionally attracted to people of both sexes.
Transgender : A man or woman whose gender identity is at odds with their biological sex.
Intersex : A person with an intersex condition is born with sex chromosomes, external genitalia, or an internal reproductive system that is not exclusively either male or female. This word replaces hermaphrodite.
1. Hillier, L., Dempsey, D., Harrison, L. et al. (1998) Writing themselves in: A National Report on the sexuality, health and well-being of same-sex attracted young people. Australian Research Centre in Sex Health and Society, La Trobe University.
2. American Academy of Paediatrics, Position Statement on Homosexuality and Adolescence (www.aap.org/policy).
3. American Academy of Paediatrics, Technical Report: Co-parent or Second-Parent Adoption by Same-Sex Parents (www.aap.org/policy).
4. Ministerial Advisory Committee on Gay and Lesbian Health, What’s the Difference? Health Issues of Major concern to Gay, Lesbian, Bisexual, Transgender and Intersex (GLBTI) Victorians. Department of Human Services, Melbourne.
5. Diamont, AL., Wold, C. (2000) Health Behaviours, health status and access to and use of health care: a population-based study of lesbian, bisexual and heterosexual women. Archives of Family Medicine 9(10): 1043-1051.
6. Harrison, AE. (1998) Primary Care of Lesbian and Gay Patients: Educating ourselves and our students. Family Medicine 28(1):10-23.
7. Mays, VM., Cochran, SD. (2001) Mental Health Correlates of Perceived Discrimination Among Lesbian, Gay, and Bisexual Adults in the United States. American Journal of Public Health 91(11): 1869-1876.
8. Diaz, RM., Ayala, G., et al. (2001) The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: findings from 3 US cities. American Journal of Public Health 91(6): 927-932.
9. Bontempo, DE., D’Augelli, AR. (2002) Effects of at-school victimisation and sexual orientation on lesbian, gay, or bisexual youths’ health risk behaviour. Journal of Adolescent Health. 30(5):364-74.
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11. Ministerial Advisory Committee on Gay and Lesbian Health, op. cit.
12. Stall, R., Paul, JP., et al. (2001) Alcohol use, drug use and alcohol-related problems among men who have sex with men: the Urban Men’s Health Study. Addiction. 96(11):1589-601.
13. Rankow, EJ., and Tessaro, I. (1998) Cervical cancer risk and pap screening in a sample of lesbian and bisexual women. Journal of Family Practice 46:139-143.
14. Daling, JR., Weiss, NS., Klopfenstein, LL. (1982) Correlates of homosexual behaviour and the incidence of anal cancer. JAMA 247: 1988-1990.
15. Jorm, AF., Korten, AE. et al. (2002) Sexual Orientation and Mental health: results from a community survey of young and middle-aged adults. British Journal of Psychiatry 180: 423-427.
16. Gonzales, V., Washienko, KM., et al. (1999) Sexual and drug-use risk factors for HIV and STDs: a comparison of women with and without bisexual experiences. American Journal of Public Health. 89(12):1841-6.
17. Clements-Nolle, K., Marx, R. et al. (2001) HIV prevalence, risk behaviours, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health 91(6): 915-921.