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LINDA DRACH CHRISTOPHER GRAY ANGIE TISSI …AND FRIENDS! Measuring and Addressing Health Disparities Based on Gender Identity and.

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Presentation on theme: "LINDA DRACH CHRISTOPHER GRAY ANGIE TISSI …AND FRIENDS! Measuring and Addressing Health Disparities Based on Gender Identity and."— Presentation transcript:

1 LINDA DRACH CHRISTOPHER GRAY ANGIE TISSI …AND FRIENDS! Measuring and Addressing Health Disparities Based on Gender Identity and Sexual Orientation

2 Gender, Sexual Orientation, and Public Health Gender and sexuality are explicitly or subtly present in much of our public health work.  Anybody here deal with issues of gender or sexuality in their professional lives?  But… Public health data systems and other evaluation/assessment tools generally are limited in their ability to capture the full range of gender and sexual expression.

3 Checking Boxes: The Binary Bind Gender and sexual orientation are different.  Compressing them into one category is generally a mess. Gender or ‘sex’ is a standard demographic variable, collected by virtually all.  Almost universally conceptualized as binary (Male or Female) Sexual orientation is now included in some large datasets; usually limited to 3 categories (hetero-, homo-, and bisexual) :  Oregon and Washington BRFSS (since ‘03)  Oregon Healthy Teens (since ‘06)  National Health Interview Study, Nurses’ Health Study II

4 How is this a Measurement Problem? Gender and sexuality are flexible social constructs that vary across location, culture, and time. Solarz et al say sexuality can be expressed in 3 ways: identity, behavior/activity, and orientation/desire. Mann added a 4 th dimension of participation in community and social groups.  Sexual identity and behavior don’t always play nice with 2x2 tables.  So, is your 3-category orientation variable measuring what you think it’s measuring? Gender is similarly complex.  A ‘Male’ or ‘Female’ category may include people with a different gender assigned at birth and/or who do not identify with the given category.

5 Queer the Census Example No sexual orientation or expanded gender ID items on 2010 Census, but measures same sex partnership and same-sex legal marriages. QtC instructed respondents to “tell your truth as you know it” because “there is no wrong answer.”  Politically legitimate: “We are developing the new portrait of America”  But increases potential for measurement error

6 How is this a Public Health Problem? Existing data point to significant health disparities based on gender identity and sexual orientation.  Historically, these data were from convenience samples: suggestive, but problematic  Now, growing evidence base from population-based datasets (mostly for differences by sexual orientation) Without good data:  Health and other social disparities among gender and sexual minorities will remain unrecognized and unaddressed  Important differences within the diverse LGBTQ community cannot be recognized and addressed  Funding for this health disparity work will be lacking

7 How Many People are We Talking About? Lack of good population estimates, but… 3.3% Portland metro area residents identified as LGB ( based on ‘03-’05 OR/WA BRFSS ) Nationally, 565,000 same sex couples ( 2008 ACS ):  1 in 6 live in rural areas  20% nonwhite  65,000 individuals who are in same-sex couples serve in the military Same sex couples live in 99.3% of U.S. counties; LGBT parents live in 97% of U.S. counties ( 2000 Census )

8 Queer: New Frontier? Queer: Claimed by some LGBT as term of self- empowerment; re-appropriated to describe S.O. or gender identity/expression that does not conform to heteronormative society  Still seen as offensive to some, particularly older LGB who may have experienced the term as derogatory (as it was indeed used through much of the 20 th century)  Wikipedia says: some use as “inclusive, unifying, sociopolitical umbrella term” (!)  Preferred by many because of its ambiguity and breadth

9 Genderqueer: New Frontier? Genderqueer: Umbrella term for all genders that are not male or female  People who identify as genderqueer may identify as both male and female, neither male nor female, or outside of the currently-understood gender continuum altogether  Emergent term (since 1990s): some like it, some don’t. Some may prefer “gender variant” or “gender nonconforming”  May include people who are transgender or intersex, but not necessarily and not interchangeable

10 A Local Example of Going Beyond the Binary Speak Out 2009 was a survey conducted among sexual and gender minorities in the Portland metropolitan area (and Benton County):  Conducted online June-July 2009  Used combination of outcropping and network sampling to recruit participants (e.g., computers at Gay PRIDE, s to various lists, Facebook, craigslist)  Eligibility: 18 and older, identify as gender and/or sexual minority, resident of Multnomah, Washington, Clackamas (or Benton) Counties in OR; Clark Co in WA  Additional outreach efforts to elders, people of color, and transgender individuals

11 Speak Out 2009, continued Survey instrument covered broad range of topics:  Health outcomes (e.g., mental and physical health conditions)  Health behaviors (e.g., use of alcohol, tobacco, and other drugs; physical activity and nutrition)  Social determinants (e.g., discrimination and harassment, experiences growing up, community connection) Survey sample was 843 individuals in the Portland metropolitan area ( Benton County analyzed separately )

12 Gender and Sexual Orientation Categories Speak Out offered:  7 categories for sexual orientation, including lesbian, gay, bisexual, queer, heterosexual, asexual, and undecided  7 categories for gender identity, including transgender (MTF, FTM, and not M or F), intersex, genderqueer, male, and female For subgroup analysis, categories were pooled into:  4 gender categories (male, female, transgender, and genderqueer)  3 orientation categories (gay/lesbian, bisexual, and queer)

13 If You Build It, They Will Come…

14 Overall Speak Out Findings—Broad Brush I Reported many risk factors for poor health; some similar to general population; elevated prevalence in some areas:  For example, like most Americans, Speak Out respondents reported eating fewer fruits and vegetables than recommended  On the other hand, mental health issues (depression, anxiety, and PTSD) and experiences of violence were prevalent, and rates appeared higher than general population rates

15 Overall Speak Out Findings—Broad Brush II Family support around sexual orientation and community connection were related to reports of better overall physical health. People with fewer experiences of social isolation reported better overall physical health. People who received more social support growing up reported less depression.

16 Differences by Gender and/or Sexual Orientation Many statistically significant differences noted between groups, suggesting that there are different health risks and experiences within the community related to gender and sexual orientation. For example:  Transgender-identified people reported less access to health care and more days of mental and physical disability  Bisexual and queer respondents reported higher rates of mental health diagnoses

17 For More Info on Speak Out 2009 Please check out our report for much greater detail on survey items, methods, and findings. Full report available at: out_2009.pdf

18 Fabulous Example of Population-Based Work, I Conron, Mimiaga & Landers. A population-based study of sexual orientation identity and gender differences in adult health. AJPH 2010 Oct; 100(10):  Compared with heterosexuals, sexual minorities (i.e., gays/lesbians, 2% of sample; bisexuals, 1%) more likely to report activity limitation, tension or worry, smoking, drug use, asthma, lifetime sexual victimization, and HIV testing.  Did not differ on 3-year Pap tests, lifetime mammography, diabetes or heart disease.  Sexual orientation disparities in chronic disease risk, victimization, health care access, mental health, and smoking merit increased attention.  More research on heterogeneity in health and health determinants among sexual minorities is needed.

19 Fabulous Example of Population-Based Work, II Dilley, Simmons, Boysun, Pizacani & Stark. Demonstrating the importance and feasibility of including sexual orientation in public health surveys: Health disparities in the Pacific NW. AJPH 2010 Mar; 100(3):  Many health disparities noted for lesbians, gay men, and bisexuals compared to heterosexuals. Bisexuals of both genders reported greatest number and magnitude of health disparities compared to heterosexuals.  Sexual orientation can be effectively included as a standard demographic variable in public health surveillance systems: justification to go beyond “don’t ask, don’t tell” surveillance.

20 Additional Overview Reading Gay & Lesbian Medical Association. Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual and Transgender Health. San Francisco, CA: GLMA, Johnson, Mimiaga, & Bradford. Healthcare issues among lesbian, gay, bisexual, transgender, and intersex (LGBTI) populations in the United States: introduction. J of Homosexuality 2008; 54(3): Mayer, Bradford, Makadon, et al. Sexual and gender minority health: What we know and what needs to be done. AJPH 2008; 98(6):


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