Corey Prachniak is an LGBT rights, HIV policy, and healthcare attorney. He serves on the Steering Committee of the Network for LGBT Health Equity and tweets @LGBTadvocacy. Views expressed herein are solely those of the author.
Part I and Part II of this series were published previously.
Over the past few weeks, I’ve argued that even as LGB (and sometimes T) rights are mainstreamed, LGBT people will remain sexual minorities, especially if one’s needs or identities (e.g., identifying as poly amorous, gender-nonconforming, etc.) make one queer or a “deviant” even by today’s standards. I’ve also argued that the major legal victories of the past decade – most notably, same-sex marriage – will improve the well-being of those whose situation, needs, and privilege allows them to take part, but will not help everybody, and will not directly end health disparities for any of us.
The fundamental problem is that the mainstreaming of “gay culture” has not been a matter of societal acceptance of the LGBT community’s diversity, but rather a reluctant allowance for LGBT people to conform to existing norms. Those of us who are queer and do not want to obey these gender and sexual norms are not only left out by this process, but are in fact harmed by being turned into ever more ignorable outcasts. And even LGBT people who identify with mainstream gender and sexual norms will not see health disparities end because of basic differences in LGBT personal health.
So, what will help end disparities – for queers and radicals, and more mainstream folks, too? There are two types of solutions: those we can tackle as individuals and those we must address as a society.
What can we do as individuals?
The “coming out” of millions over the past several decades has made the LGBT population more visible and less vilified. Now, those of us who remain on the margins need a new, queerer coming out. Only if we stand up and are counted will our diversity to be known and understood, if not celebrated, by healthcare providers, insurers, researchers, and policy-makers.
The most direct path to improving our individual health is to come out to our doctors. In an ideal world, if our doctor are unwelcoming or unknowledgeable, we could find a new one. But in reality, not all of us can dump our doctor and select another, and we often have to help educate providers on LGBT needs – one study found 50% of transgender people had to teach their doctors about transgender health. We also have to know our rights so that we don’t let providers get away with treating us in a way prohibited by law.
But beyond coming out to providers, we need to come out as queer across our social spheres, with the goal of being better understood rather than pushed further to the margins. If we are tactful, the conversations we have every day will shape our personal relationships and in the aggregate move society. We need to share why we don’t want to identify as male or female, or don’t want a monogamous relationship, or don’t want to limit our attraction to just one sex. We need to claim the power to identify as we see fit, and not to let someone else tell us at what point we “change” from being a boy to being a girl. We need to fight against the dominance of traditional social structures whose defenders seek to elevate their moral standing above “alternative” lifestyles while ignoring the Millennia of violence, subordination, and hypocrisy by which their traditions have been marked. And we need to do all this – to fight the dominance of mainstream social structures and identities – without fighting their legitimacy as an option for LGBT people who would associate with them.
Whether or not you relate to queer identities or are LGBT at all, you have a role to play if you wish to be an ally. You can be receptive when someone else expresses their identity as queer, non-conforming, transgender, or bi. You can be sensitive to the fact that some queer people have different legal, social, and healthcare needs than you. And remember: even if you identify as gender-conforming, straight, and monogamous, having the option of an alternative-but-accepted identity will increase your liberty, too.
In his seminal work The Trouble with Normal, Michael Warner argues that LGBT participation in the institution of marriage is not “simply a choice [or] a right that can be exercised privately without costs to others… Even though people think that marriage gives them validation, legitimacy, and recognition, they somehow think that it does so without invalidating, delegitimating, or stigmatizing other relations, needs, and desires.” I would not suggest that same-sex couples refrain from marrying on principle if they’ve considered it seriously and face legitimate disadvantages if they abstain. However, I agree with Warner’s point that by participating in mainstream institutions and identities, LGBT people risk legitimizing them at the expense of others. It sends a message that some relationships and identities deserve more recognition and protection than others, and thus must be better, causing stigma and psychological harm. It takes the pressure off lawmakers to offer rights, protections, and services to people who don’t benefit from existing structures. And it perpetuates the perception that some people are normal and some are deviant, even if “normal” can now include certain well-behaved gays.
Make the best choices for you and your health. But balance that self-interest with compassion for those in our community whose needs are different, and remember that same-sex marriage isn’t the end.
What can we do as a society?
While there is no set of policies that can end health disparities overnight, there are many ideas we should consider moving forward.
- We should find ways to recognize families of choice rather than perpetuate the elevation of married households above all others. We can do this by having domestic partnership laws that allow people to define their relationships themselves. DC’s domestic partnership law allows any two people to register, even outside conjugal couples. Even this law could be improved by opening it up to more than two people and increasing flexibility. And the package of rights available in such partnerships – e.g., to provide health insurance to a partner, to make medical decisions if a partner is incapacitated, and to extend legal immigration status – should be as extensive as married couples enjoy. At the same time, these agreements should be choices and not social necessities that merely take the place of marriage.
- We should formally ban discrimination on the basis of sexual orientation and gender identity by anyone providing healthcare, insurance, or related services. The Affordable Care Act, for the first time in history, bans healthcare discrimination on the basis of sex, race, national origin, age, and disability. Currently, the Department of Health and Human Services is considering how “sex” should be defined. If interpreted fairly, it will include gender identity and sexual orientation. If not, we need to push for healthcare nondiscrimination laws so that LGBT people can get the care they need without fear of mistreatment.
- We should require insurance policies cover the services necessary for transgender people who are currently denied through outright discrimination or on the basis that they are “cosmetic.”
- We should explore how to make sex work safe regardless of its legal status. LGBT people make up a disproportionate share of sex workers, who under current law are abused and prevented from having the bargaining power to demand safer sex practices. Ending stigma and financial uncertainty will also make it easier for sex workers to seek medical care.
- We need to increase access to mental health care so that those in the LGBT community who face stigma, abuse, and discrimination can get the care they need. Additionally, we need to stop stigmatizing people who take responsibility for their health and utilize these services.
- We need to support LGBT people as they age.
- We need sex education for people of all ages that is inclusive of the needs of LGBT people.
- We need to fight against tobacco and alcohol companies that target LGBT populations.
- We need researchers, healthcare providers, and government agencies to include gender identity and sexual orientation in the data they collect, and to use that data to end disparities.
- We need to invest more money in finding solutions to health problems that affect LGBT people, especially HIV/AIDS.
- We need to stop criminalizing people living with HIV and start supporting them.
The freedom to enjoy good health is a human right, and one that is unfairly hindered for many minority populations. Our health is so essential to our selves that there is no part of our life that it does not affect, and that is not affected by it.
The fight for our health is thus a fight for our selves, but also for our community. However we find and define our queerness as individuals, we deserve to live, and to live well. By challenging norms instead of bowing to them, we can ensure that no one is left behind in the struggle for health equity.
Special thanks to Rodrigo Aguayo-Romero for his help editing this piece.