I’ve been at the annual conference of the Council of State and Territorial Epidemiologists all this week. The first conference I attended was back in 2008, when I was working at the Maryland Department of Health as an epidemiologist doing influenza surveillance. I remember it being a lot of fun because I got to learn a lot from people who had the same interests as I did. This has not changed much since then, but things around us in the world have. Let me explain…
The opening plenary speaker was Dr. Rachel Levine, the Secretary of Health of the Commonwealth of Pennsylvania. Dr. Levine is a pediatrician by training. She is also transgender. She told us a brief history of her transition to identifying openly as a woman, and how she was lucky to have been in an institution that was very supportive of her finding her identity. Her talk was part of a bigger discussion on transgender health, which in itself was an even bigger discussion on disparities in health outcomes in the LGBT+ community.
One thing that stood out to me was her mentioning that SOGI (sexual orientation, gender identity) measures are not included in the US Census or on the American Community Survey, two huge sources of information on how the country is doing on all sorts of measures, from economics to health. That kind of made me realize that, yeah, we don’t often ask people about their sexual orientation or gender identity when surveying the public’s health. (Beyond the traditional male/female checkboxes in your average survey, of course.)
Asking these questions is not without some risk. We live in a society where people who are non-conforming to the gender standards of society are considered “weird,” and the sad-but-usual response form society toward weirdness is some form of neglect or abuse. Just look at how marginalized people who are homosexual can be in so many parts of our country, and the world. So adding an indicator to someone that singles them out as something other the norm can be used against them if someone so chooses… And, as we’ve seen from even the current presidential administration, people do choose to do harm to people based on their sexual preferences.
The worst form of harm comes in the shape of bullying. As Dr. Levine explained, there is nothing biologically special about LGBT+ people that makes them more prone to mental health issues. It all falls on the bully, and that bully takes different forms. It’s the dude in high school who thinks that there is a standard definition of what a man is supposed to sound and look like. It’s the boss who fires someone for being gay or for choosing to identify as something other than the gender assigned at birth. And it’s the government — like that of North Carolina — that chooses to pass legislature to make discrimination more de jure than de facto.
That bullying many times leads to the person being bullied to cause self-harm, and the worst outcome of that is suicide. This Monday, I start working at the Fairfax County Health Department in Virginia, and the person who is going to be my supervisor there delivered a quick talk about using emergency department visits to better inform public health on the prevalence of suicidal behaviors in the county. (Hers was part of a set of presentations on suicide and self-harm in different communities.) At the end of the presentations, someone asked about the data on LGBT+ people. Again, that little lightbulb in my head went off…
How do you ascertain the incidence and prevalence of suicidal ideation, self-harm and suicide attempts/completions in a segment of the population that is largely hidden away? It’s not like there is a clear indicator in a medical record that someone is non-heterosexual (or, if heterosexual, that they are transgender). It is probably mentioned in the medical notes, but do we really know how often that’s the case? For example, is it medically necessary to mention in the medical record that someone is transgender if they’re not being treated for something that is directly related to their gender identity? Then again, what is related to one’s gender identity or sexual orientation when it comes to health?
In the early days of the HIV/AIDS epidemic, most of the cases that were being identified were in homosexual men. However, we know that the virus does not discriminate. If anything, linking HIV exclusively to homosexual men made heterosexuals of all kinds feel perfectly safe from contracting it, exponentially intensifying the epidemic. In that sense, it was a mistake to only associate the epidemic with gay men. On the other hand, as we saw, it was a mistake to not be completely honest about the risk factors for contracting HIV.
So there is a lot of work to be done on this and many other fronts when it comes to public health in general and epidemiology in particular. We are going to have to figure out how to count those who are not counted, and listen to those without a voice. So let’s get to it…
René F. Najera, DrPH
I'm a Doctor of Public Health, having studied at the Johns Hopkins University Bloomberg School of Public Health.
All opinions are my own and in no way represent anyone else or any of the organizations for which I work.
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