LGBTQ Health Inequities: How Did We Get Here?

LGBTQ+ HEALTH INEQUITIES:

HOW DID WE GET HERE? In the United States today, LGBTQ+ individuals face significant health inequities in regard to disease prevalence, healthcare access, and exposure to social determinants of health. Although progress has been made in recognizing and protecting LGBTQ+ individuals in the country, a long history of discrimination and stigmatization has contributed to the persistent inequities we see within the healthcare system. An understanding of this history provides a first step in addressing such health inequities in the LGBTQ+ community.

THE PATHOLOGIZATION OF HOMOSEXUALITY Same-sex sexual attraction, relationships, and behaviors have always existed across societies and cultures, but in the 19th century a growing interest in studying the science of such behaviors emerged.

Similar to today, many conflicting theories arose with some arguing that homosexuality was a normal variation, and others arguing it to be a pathological deviance. Richard von Krafft-Ebing was a prominent psychiatrist who theorized homosexuality as a form of psychopathology. He believed that even if samesex attraction is an inborn characteristic, it should be considered a congenital disease. In contrast, psychiatrist Magnus Hirshfield posited a normative theory of homosexuality. A third theory also arose from Sigmund Freud, where he rejected both of the previous theories and instead viewed homosexuality not as an illness, but rather an arrest in sexual development. However, other psychoanalysts of the time held similar views to von Krafft-Ebing and homosexuality as pathological became the dominant stream of thought. Such thinking heavily influenced the American Psychiatric Association’s 1952 decision to list homosexuality as a mental disorder in the first edition of the Diagnostic and Statistical Manual (DSM). These theories of pathology successfully ‘othered’ individuals in the LGBTQ+ community and promoted a view of samesex sexual attraction as an illness in need of a cure.

Subsequently, a number of treatments emerged, including conversion therapy, chemotherapy treatment, and surgery all aimed at altering and preventing LGBTQ identity.

THE CRIMINALIZATION OF HOMOSEXUALITY

The pathologization of homosexuality served as justification for its continued criminalization in the U.S. throughout much of the 20th century. Sodomy laws were adopted from the colonial era and persisted as a mode of regulating public order and decency. These laws prohibited non-procreative sexual behaviors, which included, but was not limited to, same-sex sexual activity. However, in the later 20th century, the focus of sodomy laws shifted toward being a distinctive mode of discrimination against LGBTQ+ people; some states even rewrote their sodomy laws to explicitly apply to gay people. During this time when acceptance of LGBTQ+ identities was growing, sodomy laws were utilized as a mode of justifying continued discrimination against this community. For example, these laws were used to deny gay parents custody over their own children and to fire or deny gay people from jobs. Though Illinois was the first state to repeal their sodomy laws in 1961, it was not until the 2003 Lawrence v. Texas decision that the Supreme Court ruled sodomy laws unconstitutional. The recency of such a decision reveals the continued impact that sodomy laws and their associated discriminatory practices have on the LGBTQ+ community today.

THE AIDS EPIDEMIC Although co-occurring LGBTQ advocacy in the late 20th century led to the eventual removal of homosexuality in the third edition of the DSM in 1973, repeals of sodomy laws across states, and a general greater acceptance of LGBTQ identities, the stigmatization and fear felt by LGBTQ+ individuals did not disappear. And, at this same time, the LGBTQ+ community was struck with a health crisis that continues to have a profound impact on their existence in the healthcare system and society at large. The AIDS epidemic began in 1981 and has gone on to claim hundreds of thousands of lives, with a significant percentage being gay or bisexual men; today, it continues to disproportionately impact Black and Latinx gay and bisexual men and transgender women. The effects of the epidemic mirrored much of what we continue to see today: increasing acceptance of LGBTQ+ identities within society juxtaposed with legal and political battles against the community.

Public opinion polls in the 1990s indicated significant decreases in negative attitudes toward gay people. Yet, reactionaries pushed to reinstate many of the laws that previously criminalized or limited the freedom of gay people. The epidemic was largely ignored in political spheres and mass media, or when acknowledged, was often villified. Frequently referred to as the “gay plague”, the AIDS epidemic served as a mechanism for the “Moral Majority” at the time to enact further prejudice against this community. Yet, LGBTQ+ activists continued their efforts and pushed for increased visibility of the LGBTQ+ community. Their advocacy led to much of AIDS research and treatment, as well as improved health care and resources for the LGBTQ+ community, that we see today.

VIDEO: “REAGAN ADMINISTRATION'S CHILLING RESPONSE TO THE AIDS CRISIS”

Source: Vanity Fair, https://www.youtube.com/watch?v=yAzDn7tE1lU

WHERE WE ARE NOW The AIDS epidemic shed light on the discrimination toward the LGBTQ community, in the healthcare sector in particular, that continues to persist today. Significant inequalities across primary care, sexual and reproductive health, mental health, and exposure to social determinants of health remain. Thus it is imperative to prioritize this community in our health policies in order to address these current inequities.

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NBC News. https://www.nbcnews.com/feature/nbc-out/lgbtq-history-monthearly-days-america-s-aids-crisis-n919701 HIV.gov U.S. Statistics. https://www.hiv.gov/hiv-basics/overview/data-andtrends/statistics/ Institute of Medicine. (2011). Context for LGBT health status in the United States.

In The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding (pp. 25-88) Washington, DC: The National Academies Press. https://doi.org/10.17226/13128 Vanity Fair (2015). Reagan Administration’s Chilling Response to the AIDS Crisis. https://www.youtube.com/watch?v=yAzDn7tE1lU