Speaking out on GBT men's health: a critique of the Australian government's Men's Health Policy
Article Outline
Context: Australian Men's Health Policy
In its recent position paper regarding men's health, the Australian Commonwealth's Department of Health and Ageing [1] addresses the burden of disease and illness faced by Australian men. This document represents a significant advancement in both a national discussion regarding men's health and the use of a truly gendered perspective when engaging in that dialogue.
Within the document, the health of several groups of particularly disadvantaged men is addressed. These groups include Aboriginal/Torres Straight Islander men, men of a low socio-economic status (SES) and rural men, among others. It is obvious that men in those groups experience compromised health as a result of their minority group status and the social, economic and political disadvantages that are engendered through minority identification. The health of these men is important and worthy of increased attention so as to rectify the inequities described in the report.
Despite the report's exemplary identification of several groups of minority men, it is surprising that it does not expressly identify gay, bisexual and transgendered (GBT) men as a specific at-risk group. Indeed, GBT men face particularly poor health outcomes, often as a result of social homophobia that renders silent the voices of gay men and serves to impair these men's access to adequate health resources [2]. Transgender men may suffer even worse outcomes, due to their especially hidden and stigmatised place in Westernised culture [3].
Notwithstanding the exclusion of GBT men from the original draft of the Men's Health Policy, we are encouraged by the Australian Senate's enquiry into this document and the possibility for future revisions and additions to the text. Therefore, we present the following discussion of GBT men's health both to inform practitioners who may lack knowledge and understanding of this field, and to inform policy makers and other stakeholders as to the relevance of GBT health concerns to any future discussions of Australian men's health.
Health of GBT persons
Evidence abounds regarding the poor health outcomes related to GBT men. For example, Cochran [4] and King et al. [5] have both demonstrated that gay men experience significantly higher levels of psychological distress than do their straight counterparts. Rates of depression [3] and eating disorders [6], among other mental illnesses, are higher amongst gay and bisexual men. In addition, while it is universally recognised that men-who-have-sex-with-men (MSM) are an at-risk group for HIV, it is often not discussed that other sexually transmitted infections (STIs) are experienced at higher rates among gay men. Infections such as syphilis and gonorrhoea are on the rise among gay men, a trend that is counter to overall population prevalences [7], [8]. Finally, rates of illicit drug use among GBT men are staggeringly high, with some reports indicating a 52% incidence of use in the prior 6 months [9].
Transgendered men also face a variety of health challenges due to their gender minority status, as outlined in the landmark Tranznation report [10]. That report indicated that transgendered people are less likely to rate their health as “good” or “excellent” when compared to the overall Australian population and are more likely to rate their health as being “fair” or worse. Such a finding is not surprising, however, given the high rates of mental illness faced by transgendered people, including depression [10], post-traumatic stress disorder [3] and anxiety disorders [10], among other problems. These illnesses are believed to be a result of the high level of discrimination, hatred and violence faced by transgendered individuals, including that faced in health care settings [3], [10]. Rates of STIs and drug use are similarly high within the transgendered population [3], [10]. These health problems are compounded by a low level of usage of health resources by transgendered people, which is suspected to be due to both low SES and instances of discrimination in intolerant practices by health care providers [3], [10].
It is because of evidence such as this that a previous Commonwealth document [11] recognised GBT men as a disadvantaged group with regard to health outcomes. This previous inclusion makes GBT men's subsequent exclusion from the 2009 document all the more surprising, given that there is no evidence to suggest that the health outcomes described above have improved significantly over the past decade. The 2009 document's silence is deafening.
However, cultural silence regarding the health of GBT men is endemic within Westernised medicine. Contemporary health practice is arguably heteronormative in nature – that is, it falsely presumes all individuals are heterosexual [2], [3], [12], [13]. Accordingly, the health concerns of GBT men are either not recognised, or are believed to be identical to those of their straight colleagues. While it is likely that GBT and heterosexual/gender normative men share many health concerns, the manner in which these men are able to address these concerns, and interact with the health care system, is differentiated by sexual orientation. The authors of this editorial have each been involved in aspects of gay men's health for some considerable time. Through in-depth qualitative interviews focusing on a range of health-orientated issues, we have had the opportunity to listen to the voices of the men who are silenced. We have also had the opportunity to hear their experiences of difference. One gay man, who was being treated for prostate cancer, summarised this difference when he claimed “I suppose I see a hospital as being a heterosexual kind of place” [13: p. 33]. Statements such as that reveal the lack of recognition of gay men within Australian medicine, and are categorically antithetical both to the notion of empathy that should underpin medical practice and to the current Government's commitment to health for all men. Health for all cannot be achieved when hospitals are still seen as “a heterosexual kind of place.” The 2009 report, through its initial exclusion of GBT men, is not only unsuccessful in rectifying this failure, but, in fact, compounds it, through government-sanctioned indifference to the health of GBT men.
Moving Forward
As health professionals, we are called to challenge cultural practices that impair the health of individuals and populations. The silence regarding GBT men's health is one such practice that requires immediate political and cultural action. The inclusion of GBT men in all forms of social and health reform is necessary to begin the process of breaking down the heteronormative barriers that, arguably, exist in Western cultural health practices. Without this occurring the possibility of improving the health practices of GBT men are somewhat limited. Furthermore, the development of a more tolerant and compliant society with respect to sexualities will be thwarted.
Recognition of the issues that confront GBT men within the Australian Government's Men's Health Policy had the capacity to provide a previously silenced voice with the opportunity to speak out. It is remiss that such an opportunity was not recognised in the initial draft. This is arguably reflective of contemporary heteronormative practices. Given that this document is not finalised (i.e. is a “living document”), we urge that the final version take the opportunity to address this silence.
In future policy regarding GBT health, we assert that three factors should be considered. Firstly, many health care providers possess a low level of literacy with regard to broad GBT issues and, more specifically, to GBT health. This lack of awareness is documented in the literature and is suggested as being a function of the lack of training health professionals receive on these issues both in pre-service and in-service education [3], [14]. However, students who do receive such exposure tend to hold more positive attitudes toward GBT clients and attend better to the specific needs of that population subsequent to training [15], [16]. Within our professional work, we can attest to the limited level of training and discussion regarding both men's health and, specifically, GBT health within the Australian health curriculum. Through our teaching positions, we have had the opportunity to provide brief training sessions about GBT health to undergraduate and postgraduate health/medicine students, and to practicing professionals. Often, these 45-minute sessions are the only exposure these students receive about sexuality and health during their entire university career; many of the in-service professionals have said these issues were ignored in their initial coursework. Given this general silence about GBT health in the curriculum, it is not surprising that many health professionals either fail to recognise the unique needs of GBT men, or fail to recognise the heternormative or homophobic attitudes that may un-intentionally inform their practice. Recognition of the need for GBT perspectives and voices to be heard throughout the training of future health professionals could go some way to addressing this problem and altering the heteronormative attitudes that often inform contemporary health practice in Australia.
Secondly, we believe health communications, health promotion and health education must recognise that gay and bisexual men may experience health concerns differently than do their straight counterparts. Some exemplary health promotion and health education work has been done with gay men with regard to safer sex, STIs and club drugs. However, limiting GBT men's health education, and health promotion efforts to this community, to safer sex and drugs forecloses upon the range of health concerns faced by GBT men and fails to recognise that GBT men may interact with “ordinary” health concerns in “extraordinary” ways. Nowhere is this more evident than in gay men's experiences of prostate cancer [13]. Although prostate cancer can impact all men, gay men's experiences of the disease is different due to the importance of the prostate to some gay men's sexual practices and due to the sometimes ambiguous role of gay romantic partners as carers. The men in that study said little gay-specific information was available about prostate cancer and their health care providers often lacked this knowledge. Therefore, the development of health communication materials that address a range of health concerns from a GBT perspective would prove to be an invaluable resource in improving the state of GBT health in Australia
Finally, we suggest that future policy regarding GBT men's health take seriously the notion of health promotion, as described in the influential “Ottawa Charter” [17] and future iterations of that document. We must begin to influence the community beliefs and standards surrounding health, both within GBT communities and the Australian population more generally. Practices that impair health must be addressed, including homophobia and heteronormative practices that only serve to discriminate against a large segment of the population and give the suggestion that GBT men are, in fact, less worthy of respect than are straight men. These efforts must begin in the schools and other cultural institutions that influence the cultural and moral development of our youth. This initiative must be reinforced by the manner in which policy makers and other stakeholders engage with future discussions of GBT issues. It sets a dangerous double standard to claim to value the health of all men while simultaneously enacting legislation (or failing to overturn legislation) that marginalises a proportion of the population. Addressing homophobia in all aspects of government is a means by which to promote health. The current “live document” needs to take into consideration this form of health promotion as a matter of urgency.
We recognise that the Policy is a work-in-progress. Through the consideration of the above arguments, and the inclusion of GBT men, we assert that future drafts of the document can more fully embrace its mission of promoting health for all men.
Summary
Gay, bisexual and transgender (GBT) men in Western cultures experience a number of poor health outcomes related to mental health, sexually transmitted infections (STIs), drug use and other health-related issues. These concerns are largely related to GBT men's stigmatised location in Western cultures.
The Australian Government's recent Men's Health Policy document overlooks the special health concerns of GBT men, despite including discussions of the health concerns of numerous other groups of minority men.
This oversight is demonstrative of heteronormative attitudes that are endemic to contemporary medicine in Australia and serve to perpetuate the cultural silence that exists with regard to gay men's health.
Improved education regarding GBT health, the production of GBT-specific health communications and changed cultural practices with regard to GBT men are suggested as avenues by which to improve the health of GBT men.
The Australian Government is urged to re-consider this oversight in future drafts of this document.
References
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PII: S1875-6867(09)00066-9
doi:10.1016/j.jomh.2009.04.005
© 2009 WPMH GmbH. Published by Elsevier Inc. All rights reserved.
