Lesbian, Gay, Bisexual, and Transgender Public Health: Progress and Challenges

Abstract

Ten years ago, when I left my position as an assistant commissioner at the Massachusetts Department of Public Health, very few state—or local or federal—health departments mounted health initiatives targeted at lesbian, gay, bisexual, or transgender (LGBT) populations. The only exception involved HIV/AIDS, which the large numbers of HIV-positive gay and bisexual men made virtually (although not always) impossible to ignore. Over the past decade, several city health departments, including the one I led as commissioner of health for Boston, have created staff positions or offices to address the health of the LGBT community. Yet, when I returned to the Massachusetts Department of Public Health a year ago, I found that there had been little progress at the state level in addressing either the diverse health needs of LGBT populations or the complex ways in which discrimination negatively affects health—even though, in the interim, there had been important and groundbreaking efforts, such as the founding of the National Coalition of LGBT Health and the publication of the Healthy People 2010 Companion Document for LGBT Health. In addition, of course, the LGBT community made significant progress in other arenas, including the historic legalization of gay marriage in Massachusetts, where the marriage licenses of gay couples are proudly filed alongside those of heterosexual couples. Outstanding researchers like the ones whose works are highlighted in this edition of the Journal are admirably addressing a range of public health issues that affect the LGBT community, including smoking, violence, chronic disease, tuberculosis, and access to care. The emphasis of much of the published work, however, continues to be on HIV and sexually transmitted diseases. While this work is essential, so is the need to increase the range of the subject matter. The current, overly narrow focus on HIV and sexually transmitted diseases within the LGBT community reflects the continuing existence of homophobia and transphobia, but it also results from the rarity with which data on sexual orientation and gender identity are collected in public health or clinical settings. The vast majority of our survey instruments do not inquire about these characteristics (to be fair, neither do they ask about economic class or ethnicity). This leaves anecdotal observation or limited-size studies as the only evidence of which health conditions and risks disproportionately affect LGBT populations. We can observe the impact of this barrier in this special issue of the Journal, the content of which makes it clear that some of the finest researchers in the country have an easier time getting funding for their work when they focus on sexually related conditions. This is unfortunate. It brings to mind other stereotyping of specific populations (e.g., categorizing women’s needs as being mainly about reproductive health, and assuming that adolescent needs are mainly about drugs and sex). Both the public and the private sectors need to address this deficiency. We can learn from the recent successful efforts of numerous cities and states to implement major initiatives to combat racial and ethnic health disparities, which have included improved collection and analysis of data. Without a greater foundation for routinely obtaining accurate population-based data, though, researchers will continue looking at the same incomplete picture. In addition, the public health community will lack the information it needs to understand and address the health issues of LGBT communities. The Journal’s necessary attention to LGBT health will advance this effort—not only by showcasing superb researchers who help us gain useful insights, but also by reminding us of the important work yet to be done.