Abstract
The World Health Organization's (WHO's) social determinants of health discussion underscores the need for health equity and social justice. Yet sexual orientation was not addressed within the WHO Commission on the Social Determinants of Health final report Closing the Gap in a Generation.
This omission of sexual orientation as a social determinant of health stands in stark contrast with a body of evidence that demonstrates that sexual minorities are disproportionately affected by health problems associated with stigma and discrimination, such as mental health disorders.
I propose strategies to integrate sexual orientation into the WHO’s social determinants of health dialogue. Recognizing sexual orientation as a social determinant of health is an important first step toward health equity for sexual minorities.
Health equity and social justice are central to the World Health Organization’s (WHO’s) discussion of the social determinants of health.1 The WHO’s Commission on the Social Determinants of Health (CSDH) 2008 final report, Closing the Gap in a Generation, defined social determinants of health as living conditions shaped by sociopolitical factors that contribute to the health of individuals and populations.1 The social determinants of health were operationalized in nine themes: early childhood development, globalization, health systems, employment conditions, priority public health conditions, measurement and evidence, women and gender equality, urbanization, and social exclusion.
The CSDH social determinants of health conceptual framework posits that factors associated with the distribution of health and well-being include social position, education, occupation, income, gender, and ethnicity/race.1 Sexual orientation was not included within CSDH’s social determinants of health conceptual framework nor mentioned anywhere in this report.1 Yet sexual minorities experience significant and pervasive health disparities. (I use the terms “sexual minority” and “lesbian, gay, bisexual” [LGB] interchangeably to convey nonheterosexual sexualities and identities claimed by persons across diverse cultures and contexts.) For example, systematic reviews and population-based studies report increased risks for depression,2–7 suicidal ideation,2,3,7–9 anxiety,2,3,5–7 and substance dependence2,4,6 among sexual minorities compared with heterosexuals.
A woman prays next to the coffin of Erick Alex Martinez, a journalist and gay rights campaigner, who was murdered in Honduras along with at least 20 other media workers over the last 3 years. Martinez's body was found by the roadside in the village of Guasculile, north of the capital, Tegucigalpa. He worked for an association defending lesbian, gay, bisexual, and transgender (LGBT) rights. Martinez had also been chosen last year as a candidate for a coalition of parties that emerged after the ousting of President Manuel Zelaya in 2009. Photograph by Orlando Sierra. Printed with permission of Getty Images.
Omission of sexual orientation as a social determinant of health in Closing the Gap in a Generation stands in stark contrast with a large body of evidence that demonstrates that sexual minorities are disproportionately affected by health problems associated with stigma and discrimination.2,5,10 Homosexuality is criminalized in 76 countries and punishable by death in five,11 underscoring the impact of powerful sociopolitical factors on the lives of sexual minorities. Sexual minorities are a demographic that account for a significant proportion of the global disease burden, which is strongly impacted by sociopolitical factors; therefore, they should be included in health equity discussions. My objective is to demonstrate the importance of explicitly recognizing stigma and discrimination targeting sexual minorities as a social determinant of health to promote health equity.
Across the globe, stigma and discrimination heighten the vulnerability of sexual minorities to inequitable health outcomes.12,13 Sexual stigma refers to devaluing of sexual minorities, negative attitudes, and lower status afforded to nonheterosexual behaviors, identities, relationships, and communities.14 These stigmatizing processes may result in social and institutional discrimination and exclusion targeting sexual minorities.13,14 Mental health disorders are an illustrative example of the disproportionate burden of illness experienced by sexual minorities associated with stigma and discrimination.
Sexual minorities are at elevated risk for mental health disorders compared with heterosexuals. A systematic review of mental health among LGB persons that included 25 studies with heterosexual (n = 214 344) and nonheterosexual (n = 11 971) persons from seven countries in North America, Europe, and Australia highlighted that LGB people were at increased risk for suicide attempts, depression, anxiety, and alcohol or substance dependence.2 A population-based study in Canada (n = 49 901) revealed more mood or anxiety disorders and an elevated history of lifetime suicidality among gay or bisexual men compared with heterosexual men.3 In the United States, a population-based study4 (n = 2272) indicated that sexual minorities experience a 5% to 11% excess mental health burden compared with heterosexuals. Chronic stress resulting from stigma and discrimination contributes to these mental health disparities among sexual minorities.5,15
Meyer’s5,16 minority stress model outlined multiple stressors in the lives of sexual minorities: internalized homophobia, in which negative social attitudes contribute to shame and reduced self-worth; perceived stigma, referring to fear and expectations of rejection; and discrimination, including violence. Internalized homophobia has been associated with increased relationship problems17 and depression18 and reduced HIV knowledge19 among sexual minorities. Perceived stigma may result in people hiding their sexual orientation, which in turn compromises health care access and appropriate care.10,16,20–22 A recent Institute of Medicine report23 recommended that sexual orientation data be collected in health records to identify and address LGB health disparities; discomfort and lack of knowledge among physicians present barriers to collecting such data. Discrimination predicted psychological distress in multisite probability samples of Latino gay or bisexual men15 (n = 912) and LGB youths24 (n = 9188) in the United States. Sexual and physical violence targeting sexual minorities is a global phenomenon.25–27 Higher risk of onset of posttraumatic stress disorder among LGB people than among heterosexuals in a national United States study (n = 34 653) was in part attributed to LGB people’s greater exposure to interpersonal violence.28 Taken together, these studies provide strong support for the association between social contexts of stigma and discrimination and deleterious mental health outcomes among sexual minorities.
Understanding risk factors for depression and other mental health disorders is key to decreasing global mental health morbidity.29,30 A recent articulation of grand challenges in global mental health highlighted the identification of modifiable social risk factors as a chief priority.31 Enhanced understanding of stigma and discrimination targeting sexual minorities as a social determinant of health—a modifiable social risk factor—underlying health disparities can guide the development of “community environments that promote physical and mental well-being throughout life.”31(p29) Including sexual orientation in social determinants of health dialogues may also inform culturally sensitive health promotion programs and interventions for sexual minorities.
The CSDH could identify sexual orientation as a sociodemographic characteristic in its conceptual framework,1 similar to how gender and race/ethnicity are positioned. This framework lists several sociodemographic variables (i.e., education, occupation, income, gender, ethnicity/race) associated with societal norms and values, psychosocial factors, and distribution of health and well-being. A vast evidence base demonstrates that sexual orientation is a sociodemographic variable associated with the distribution of health and well-being2,5,10,32—and could therefore be considered a social determinant of health.
A recent commentary called for the CSDH to adopt an intersectional approach to gender33 to account for the interactions between identity categories (e.g., race, gender, sexual orientation). In a similar way, discussions of sexual orientation should highlight the cultural and context specificity of conceptualizations of sexuality, experiences of stigma, and health outcomes among diverse sexual minorities.10,14,34 To illustrate, a recent study highlighted increased risk of suicide among Black and Latino LGB youths in the United States compared with White LGB youths.35 A population-based US study reported that LGB adults who reported discrimination based on race, gender, and sexual orientation had nearly four times greater odds of past-year substance use disorders than did LGB people who did not report discrimination.36 Attention to the convergence of sexual orientation with other identity categories is critical to improving health outcomes.
The CSDH report1 is structured to highlight “evidence for action” and “what must be done” for categories such as gender equity and provides insightful examples of health inequities among various countries and populations. Integrating evidence of health disparities among LGB people associated with stigma and discrimination can enrich this report’s analyses and scope. Gender equity constitutes its own chapter and is integrated throughout various dimensions (e.g., mental health determinants, political empowerment) of the report; sexual minority issues could be incorporated by using a similar approach.
Sociocultural factors such as stigma and discrimination contribute to global health disparities among sexual minority individuals and populations. As the leader in global health, it is imperative that the WHO addresses sexual orientation in its health equity dialogues. Estimates from population-based studies in the United States indicate that 3.5% of the population—approximately nine million people—identify as lesbian, gay, or bisexual.37 Even conservative global population-based estimates of 1.2%37 suggest that sexual minorities constitute at least 84 million of the world’s population.38 Sexual minorities constitute a significant proportion of the global population and warrant inclusion in health equity dialogues.
I recommend two actions, which are supported by the existing body of evidence. First, the WHO should include sexual orientation as a social determinant of health as its own category in future CSDH reports and on its Web site. This would strengthen advocacy, policy, and programming to promote social justice. Second, the WHO should explicitly reference sexual orientation and sexual minorities within various categories (e.g., social exclusion, mental health determinants, political empowerment). Paul Hunt, former United Nations Special Rapporteur, on the right to the highest attainable standard of health, described an “underdeveloped and understated”39(p36) human rights analysis in the CSDH document resulted in “missed opportunities.”39(p36) Likewise, I have highlighted opportunities to address sexual orientation to develop a more comprehensive, inclusive health equity analysis.
Social injustices are endangering the health of sexual minorities. The WHO has the power to influence policy to promote health equity and social justice for sexual minorities. Although the WHO’s recognition of sexual orientation as a social determinant of health will not automatically translate into health equity, it is an important first step. For the WHO to successfully meet its objective to close the gaps in health disparities in a generation, inequities among sexual minorities must be addressed.
Acknowledgments
The author received salary support from a Canadian Institutes of Health Research fellowship during preparation and writing of this article.
The author would like to thank Tonia Poteat (PhD candidate, Johns Hopkins School of Public Health) and Peter A. Newman (professor, Factor-Inwentash Faculty of Social Work, University of Toronto) for valuable feedback and thoughtful comments during article preparation.
