Time to recognise sexual orientation as a social determinant of health

The outcome of a recent Senate Community Affairs References Committee inquiry into Australia’s response1 to the World Health Organization’s report on the social determinants of health2 makes for welcome reading, particularly for lesbian, gay and bisexual Australians. Encouragingly, the Senate Committee has acknowledged what many of us already know — that sexual orientation, conceived of as the dynamic interaction of attraction, behaviour and identity, functions as a social determinant of health.

The original WHO report, while containing many laudable recommendations, failed to mention sexual orientation as a social determinant of health.2,3 This is a particularly concerning omission in a world where lesbian women are subjected to “corrective” rape; where gay and bisexual men are prosecuted, and sometimes put to death, because of who they are; and where inequities in health persist for people who identify as lesbian, gay, bisexual, trans or intersex (LGBTI) more broadly.4 While degrees of violence and discrimination differ between countries, they remain pervasive, including in Australia.5 A literature review of Australian and international studies found that LGBTI populations experience mental health disorders at a significantly higher rate than the general population.6 This difference is evident across the life course, and a higher risk of suicide is of particular concern. Moreover, a recent Australian study highlighted a rise in physical and verbal abuse directed at same-sex-attracted and gender-diverse students in Australian schools, with obvious implications for the mental health and wellbeing of these young people.7

In light of these findings, the failure to consider sexual orientation as a social determinant of health has been particularly pronounced in the Australian context. A landmark 2009 report, ostensibly analysing how Australia was faring with regard to social inclusion, did not examine the health and wellbeing of LGBTI people across a single indicator.8 At the heart of this omission is the politics of who counts and, by implication, who does the counting; a situation compounded by a profound failure to engage with the lived realities of LGBTI people, which include experiences of discrimination. Health and social interventions are impeded by a lack of routinely collected data to inform policy development, a situation admittedly not unique to LGBTI populations.9 This often results in inaction in the face of need.

We argue that recognising sexual orientation as a social determinant of health, instead of treating it as the elephant in the room, is vital to meeting the health needs of LGBTI people and challenging the discrimination and violence that still mark the lives of many. The challenge facing us now is how best to “mainstream” this idea, so that when people think of the social determinants of health along the familiar axes of socioeconomic status, gender and country of birth, they actively consider sexual orientation too. This extends to the conduct of research, including survey design and refining minimum data standards that underpin routine public health data collection, as well as policy development and service delivery. The WHO report itself calls for as much, when it proposes expanding the definition of health literacy beyond an awareness of factors affecting individual health to include those affecting the health of population groups, including discrimination based on sexual orientation.2

Recognising sexual orientation as a social determinant of health requires a concerted and sustained effort to foster the political will to create change. But political will is not the provenance of politicians alone — civil society organisations and public health practitioners need to cultivate it. If the Senate report is a stepping stone, we need to take bold new steps. The challenge — and opportunity — now is to turn the rhetoric into reality through our collective actions. The historic passage through federal Parliament of amendments to the Sex Discrimination Act 1984 (Cwlth) in June 2013, providing protection from discrimination on the basis of sexual orientation, gender identity and intersex status, is one positive step in this direction.