Healthcare Rights for Gender and Sexual Minorities

Abstract

There is broad consensus that a key factor for human flourishing is access to safe, effective, and appropriate healthcare. Whilst health inequalities exist for many marginalised and minoritised groups, the impact of broader social inequities on healthcare delivery and health outcomes is particularly notable in gender and sexual minority groups. Health inequalities faced by Lesbian, Gay, Bisexual, Transgender, Intersex, and other gender and sexual minority groups exist across domains of physical, psychological, and emotional wellbeing; many stemming from experiences of broad social exclusion and discrimination, explained through the concept of ‘Minority Stress’. This chapter will explore the concept of health inequality and inequity faced by LBGTQI+ groups, considering the relationships between social inclusion, legislative protection, and access to healthcare. It will also question why, even in societies with high acceptance rates of gender and sexuality diversity, health inequalities remain evident. Furthermore, the chapter will present strategies to enhance the healthcare rights of sexual and gender minority groups.

1. Introduction

This chapter will discuss the health and healthcare of Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex people, framing it as an issue of human rights. Across the world, there are significant differences in the visibility, participation, and access to civil and legal rights for gender and sexual minority communities, which inevitably intersects with the availability and accessibility of appropriate healthcare and, ultimately, health outcomes for these groups.

Some key differences between gender and sexual minority communities and other minoritised and marginalised groups are that they are not always recognisable through their appearance or physical characteristics. They are not necessarily born into or socialised within these groups, and in many cases, the minoritisation and marginalisation they face are directly linked to societal perceptions that their lived experiences are unnatural, and that they are somehow way disordered [1].

Whilst research into the health of gender and sexual minority communities remains limited in many contexts, this chapter will put forward some of the areas where health disparities and inequalities are established, as well as discuss some of the confounding factors around these inequities including experiences of discrimination, stigma, and minority stress [2]. These inequalities both directly and indirectly link to wider issues of LGBTQI+ rights.

Addressing gender and sexual minority healthcare as a right is dependent on the realisation of other human rights, but also in the understanding and acknowledgement of specific healthcare needs of LGBTQI+ communities. This chapter puts forward an argument as to why issues of health equity for these communities should be considered through a Human Rights lens. There are also more specific issues put forward where human rights abuses intersect with healthcare such as the case of conversion practices to change gender and sexual minority identity, often framed as therapy, and surgical violence perpetrated on intersex individuals.

2. Gender and sexual minority rights around the world

Globally there has been an overall positive shift towards more visibility and recognition of the rights of LGBTQI+ people. However as pointed out by the Council of Foreign Relations [3] this shift in progress has not been evenly experienced; whilst there are growing numbers of countries decriminalising homosexuality, ensuring legal protections, recognising partnership rights, and the right to legally change gender, in other jurisdictions there has been growing opposition to LGBTQI+ rights.

Since the 1970s, there has been consistent campaigning and social activism to combat the oppression, inequality, and injustices faced by gender and sexual minorities, stemming from many legal and societal injustices with roots in nineteenth century colonial laws [4]. Initially, these movements were very much focused on safety and opposition to violence and the criminalisation of LGBTQI+ people.

The Stonewall Riots, which occurred in response to police brutality and oppression experienced at the Stonewall Inn, a gay bar in New York, marked the most notable event during the early period of LGBTQI+ activism, as LGBTQI+ people fought back against the violence and discrimination they faced by taking to the streets. Whilst this is often seen as the beginning of the modern LGBTQI+ rights movement, it was neither the first, nor arguably the most impactful activism of the time [5]. The ‘Stonewall Myth’ as described not only obscures history, and ignores the contextual nature of global LGBTQI+ movements; LGBTQI+ rights have a particular history and approach within the particular context they appear. It is important to remember when considering the history of LGBTQI+ rights that discussions around legal protections, recognition, partnership rights, and access to services can be hard to grasp in areas where there is an immediate and direct threat to safety and life.

Legal protections for LGBTQI+ individuals vary widely across different regions of the world; and how LGBTQI+ communities view the role of the legal system, whether as oppressor, or liberator, concurrently differs. Some countries have laws that protect LGBT individuals from discrimination, conflictingly others have laws that criminalise same-sex behaviour. According to a report by the International Lesbian, Gay, Bisexual, Trans, and Intersex Association (ILGA), as of 2020, 70 countries still criminalise same-sex behaviour, with punishments ranging from fines to imprisonment, and even the death penalty in some jurisdictions [6]. In many of these countries, laws which are used to persecute and criminalise gender and sexual minorities have roots in colonial penal codes; however, it is too simplistic to suggest that just simply revoking such laws would lead to societal acceptance and freedom from persecution. Indeed, in some jurisdictions such as India and Uganda, former colonial laws were repealed and subsequently replaced with new laws which criminalise LGBTQI+ communities to some extent. Addressing LGBTQI+ inequality on a global scale needs to be done cautiously and with cognisance to this history [4], what is happening in many cases is that the promotion of LGBTQI+ rights is being seen as a Western dictate, and almost as a new form of colonialism, this is why a clear human rights approach is favourable.

Although legal protections are vitally important in the promotion of gender and sexual minority rights, this does not necessarily lead to a concurrent shift in societal views, which are often linked to cultural and religious norms. In many countries, where there is widespread stigmatisation of sexual and gender minorities, their lifestyles are considered immoral or against cultural norms. This stigma can have a profound impact on LGBT individuals’ mental health and well-being, leading to feelings of shame and self-hatred [2]. In some countries, the threat and experience of violence, harassment, or persecution of LGBTQI+ individuals, leads in turn to fleeing their homes or seek asylum in other countries as described by the UN High Commission for Refugees in their discussion paper [7].

Societal stigma and discrimination against gender and sexual minorities are widespread and take many forms, such as verbal and physical abuse, exclusion from commercial or social activities, and indeed physical violence. LGBTQI+ individuals may also face discrimination in employment, housing, and access to health care. These issues are not only experienced in contexts where there is criminalisation of gender and sexual minorities, but is commonly experienced, even in jurisdictions with legal protection. The ILGA Europe reported that 2022 saw the deadliest rise in anti-LGBTQI+ violence in over a decade across Europe and Asia [8]; and similar trends are being seen in other parts of the world, with statistics from the USA national crime victimisation survey 2017–2019; LGBT individuals are more likely to experience hate crimes than non-LGBT individuals, and these experiences have a significant and lasting impact on health and wellbeing [9].

Concurrent with the criminalisation and stigmatisation of gender and sexual minority communities, there has also been an attempt in many contexts to pathologise LGBTQI+ identity. Homosexuality and gender non-conformity are seen as either symptoms of, or diseases in themselves. Homosexuality was classified as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until 1978, and it was only in 2018 that the World Health Organisation declassified transgender identity as a mental illness [10]. The theories of pathologisation are grounded in the belief that the presence of atypical gender or sexuality behaviour are symptoms of a disease or disorder to which a medical professional should attend to [11]. In a similar vain to the dichotomy of a justice system which can either be seen as a liberator or oppressor, the relationship between LGBTQI+ individuals and healthcare providers can be complex. This perspective then further adds to stigmatisation and non-acceptance in society more generally.

The international human rights community has been strong in advocating for the rights of LGBTQI+ individuals. Organisations such as the United Nations, Council of Europe, World Health Organisation, and Amnesty International have all advocated for the decriminalisation and de-pathologisation of homosexuality, and in promoting sexual and gender minority rights as human rights. In addition to being linked to core human rights values such as respect for the dignity, liberty, and autonomy of the individual, as well as rights related to life and safety, the right to good health and appropriate healthcare for gender and sexual minorities is a key intersection that this chapter will discuss.

3. Healthcare as a human right

In initially addressing the substantive issue of gender and sexual minority healthcare as a human right, it is important to acknowledge that this chapter proposes, more generally, that universal healthcare is a human right for all. This stance, although widely accepted within the community of human rights scholars and practitioners, is not universally accepted; and for some, healthcare should be treated as a commodity rather than a right.

The concept of healthcare as a human right has its origins in the Universal Declaration of Human Rights (UDHR) adopted by the United Nations in 1948. The UDHR has become the foundational document for modern understanding of human rights and outlines the basic human rights that every person is entitled to, including rights to life, security, and safety. It explicitly recognises the right to healthcare by stating that ‘everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including medical care’. The UNDHR is subsequently supported in this statement by various subsequent international treaties, instruments, and covenants, such as International Covenant on Economic, Social, and Cultural Rights, the EU Charter on Human Rights, the European Convention on Human Rights, and the African Charter on Human and Peoples’ Rights.

The founding basis for establishing access to healthcare as a human right is the understanding that illness, injury, and preventable disability can not only be a threat to life itself but can also hinder human flourishing and the realisation of other fundamental human rights.

Opponents of the idea that healthcare is a human right argue that healthcare is a service or commodity, and therefore, like any other service or commodity, it should be provided based on the principles of supply and demand. One challenge is that there is a perceived vagueness in support for universal healthcare, as the distinction between needs/fundamental and preferences/amenities is not always made clear in debates on universal healthcare provision [12]. For them, there is a fundamental difference between providing life preserving care and what is considered more elective healthcare.

Whilst opponents of universal healthcare as a human right do not refute that basic health is necessary for human flourishing, they still contend that the government’s role in healthcare should be limited to providing a regulatory framework that ensures quality standards are met and promotes competition amongst healthcare providers. For some, a key issue in provision of healthcare as a universal right is the role of lifestyle and behaviour in the fulfilment of good health outcomes. In an era where many public health crises worldwide are linked to preventable conditions like cardiovascular disease, diabetes, and obesity, questions arise about how to consider individual behaviours and strike a balance between the choice to engage in unhealthy behaviours and the right to access healthcare to address negative outcomes [13].

Undoubtedly, healthcare services are expensive, and providing them as a fundamental human right places a significant financial burden on governments and healthcare providers. It may also be argued that considering universal healthcare as a human right would lead to an overburdening of the health system, because of an inability to discriminate based on issue of acuity and need. If everyone tried to access healthcare benefits to maximise their wellbeing to the full extent possible, it would be impossible to provide, and ultimately result in the failure of the system. Viewing healthcare provision as a continuum that encompasses health system planning, education, health promotion, and service delivery can help to mitigate its burdensome expense.

Despite the ongoing debate on whether healthcare is a human right, evidence suggests that healthcare as a human right has numerous benefits. The WHO World Health report in 2010 found that countries that provide universal healthcare coverage have better health outcomes than those that do not [14], countries with universal healthcare coverage had lower rates of infant mortality, lower rates of deaths from preventable diseases, and higher life expectancies. Inevitably this approach leads to significant economic benefits with more opportunity for participation in the economic activity of any society, as well as a society where people can realise their rights more fully. There is also evidence that the provision of universal healthcare coverage leads to higher economic growth rates for countries that provide when compared to those that do not [15].

Furthermore, advocates of healthcare as a human right argue that healthcare services should be accessible to everyone, regardless of their social status, race, ethnicity, gender, or sexuality. Asserting that the provision of healthcare services should not be based on one’s ability to pay but on the principle of equal access to healthcare services. This is based on the idea that healthcare is a public good and that the benefits of good health are shared by everyone in society.

Providing healthcare services as a human right has been found to reduce health disparities; simply put, by removing cost as a barrier, countries that provide universal healthcare coverage have lower rates of health disparities compared to those that do not [16]. This is because universal healthcare coverage ensures that everyone has equal access to healthcare services, regardless of their social status or income.

Universal healthcare provision, however, should not mean the same healthcare provision for everyone. Healthcare needs are diverse, some groups face particular health inequalities and disparities which require unique and specific interventions. In the next section, I will describe some of the health inequalities faced by gender and sexual minorities.

4. LGBTQI+ health inequalities

This chapter contends that universal healthcare is a human right for all, but it is important to note that healthcare must also be appropriate, culturally responsive, and address the specific needs of those who access it. One size does not fit all, and one approach to healthcare does not address the needs of all either. Lesbian, gay, bisexual, transgender, queer, and intersex individuals have specific health needs and related to the specific health disparities and inequalities that they face. These disparities and inequalities are attributable to a range of social, economic, and cultural factors, including lived experiences of discrimination, stigma, and prejudice. Research has shown that LGBTQI+ individuals experience higher rates of mental health issues, problematic and harmful substance use, sexually acquired infections (STIs), body image issues as well as higher prevalence and poorer outcomes related to other physical health conditions when compared to their non-LGBTQI+ peers [17]. The field of LGBTQI+ health studies is an emerging area of research, there is much we do not know about LGBTQI+ health; however, addressing the inequalities and disparities we do know about is a good start.

Mental health issues are some of the most significant and recorded health disparities experienced by LGBT individuals. Several studies have found that LGBTQI+ individuals have higher rates of depression, anxiety, and suicidal ideation compared to their non-LGBTQI+ peers [18].

The mental health disparities experienced by sexual and gender minority individuals are attributable to a range of social, economic, and cultural factors. Discrimination, stigma, and prejudice are significant contributors to these disparities. LGBTQI+ individuals face discrimination in various forms, including employment, housing, and healthcare and this discrimination can lead to social isolation, low self-esteem, and a sense of hopelessness, which can contribute to mental health problems [2]. A significant contributing factor to this may be that the isolation and exclusion experienced by many LGBTQI+ people in their youth, may also be attributed to poorer mental health outcomes, with adverse childhood experiences having a major impact on mental wellbeing later in life [19].

Substance use disorders are another significant health issue experienced within gender and sexual minority communities, linked in many ways to poorer mental health. Several studies have found that LGBTQI+ individuals have higher rates of substance use disorders compared to their non-LGBTQI+ peers and the health impacts are multifaceted and complex [20, 21]. The factors that contribute to substance abuse disparities amongst LGBT individuals are complex and multifaceted. Discrimination, stigma, and prejudice are significant contributors to substance abuse disparities.

Whilst substance use may be a coping strategy for many individuals who experience social isolation, stigma, and discrimination within gender and sexual minority communities, it is important to note that in many of these communities, alcohol and other substances perform an important role in socialisation, and the substances and norms associated with these communities are diverse and contextual [22].

Rates of Sexually transmitted infections (STIs) and HIV continue to have a more significant burden in communities of gender and sexual minorities than the general population, particularly in communities of Gay and Bisexual men and Trans people [23, 24, 25].

In the 1980s and 1990s, during the height of the HIV and AIDS epidemic, Gay, Bisexual men, and the Trans community were some of the most impacted by the new virus, which was killing most people infected. Communities of LGBTQI+ people were also at the forefront of political action to ensure adequate resources and appropriate information were provided. Treatment for HIV has now significantly improved to mean that people living with HIV can live full and healthy lives. However, a significant impact of the burden of HIV and STIs within LGBTQI+ communities is the shame and stigma associated with infectiousness and transmissibility of these diseases [26]. People living with HIV on effective treatment can no longer transmit the virus to sexual partners, however, the message around undetectability and transmissibility is not as well-known as it could be.

Few issues in health and medicine receive as much focus as cancer, and given that it is one of the leading causes of death globally, this focus is undoubtedly justified. However, much of the rhetoric surrounding cancer is generic and generalised, despite emerging evidence indicating that gender and sexual minority individuals may be at higher risk for certain cancers than the general population. Lifestyle and behavioural issues are often key factors in the development of cancers, excess alcohol and drug usage as well as higher prevalence of STIs such as HPV in LGBTQI+ may have an impact on the development of cancer.

Data about cancer risk amongst members of the LGBTQ community is limited, however, some recent studies have found that this group may have an elevated rate of cancer diagnoses. In a review of the 2013–2016 US National Health Interview Survey, a comparison was made in cancer diagnoses between 129,431 heterosexual adults and 3357 lesbian, gay, and bisexual adults [27]. Gay men had over a 50 percent increased likelihood of reporting a cancer diagnosis compared to heterosexual men. Likewise, compared to heterosexual women, bisexual women had a 70 percent greater likelihood of reporting a diagnosis of cancer, although the authors suggest that this figure may be an underestimation due to the possibility of non-disclosure of LGBTQI+ identity status.

As with the areas of health and illness discussed above, data on the prevalence and aetiological links between sexual and gender identity and experiences of other chronic illness is sparse. LGBTQI+ people are often invisible, and if demographic data on sexual and gender identity is not gathered, causative links cannot be identified.

The dearth of research around sexual and gender minority experiences of chronic illness aside from HIV plays a particular role in stigmatising gay men’s health issues in particular [28], with LGBTQI+ healthcare only being seen as HIV and sexual healthcare. Using the American National Health Interview Survey data, it was identified that there were some areas where LGB people had higher prevalence of certain disease categories, sexual minority men in particular identified as having higher prevalence of coronary disease and cancer [29]. With a universally ageing population, focus should be given to the experiences of LGBTQ people living with chronic illness. In a qualitative survey of 190 LGB people exploring experiences related to 52 different non-HIV related chronic illness, four distinct themes emerged: ableism within LGBT communities, isolation from LGBT communities, heteronormativity within healthcare, and homophobia from healthcare staff [30]. Regardless of prevalence of illness or disease, the clear disparities in access, experience, and utilisation of healthcare by sexual minorities warrant particular focus.

In conclusion, gender and sexual minority communities experience significant health inequalities and disparities that are attributable to a range of social, economic, and cultural factors. Mental health problems, substance use disorders, STIs, and healthcare disparities are amongst the most significant health disparities experienced by LGBTQI+ individuals. Discrimination, stigma, and prejudice are significant contributors to these disparities. Addressing LGBTQI+ health inequalities requires a multifaceted approach that addresses the social, economic, and cultural factors that contribute to these disparities. Strategies to address these disparities include increasing access to healthcare, addressing discrimination, stigma, and prejudice, and supporting LGBTQI+ communities.

5. Intersections between sexual and gender minority health and wider human rights

A key limitation in gender and sexual minority healthcare is the absence in data around LGBTQI+ health experiences or outcomes, in many cases this is because sexual orientation and gender identity data simply is not collected in healthcare provision or research. In contexts where gender and sexual minority communities are not recognised, and particularly in cases where these identities are persecuted and criminalised, it is obvious why this is the case; it would be dangerous to gather data which could be used against individuals or communities. However, there is also evidence that LGBTQI+ people more generally hesitant to share their sexual orientation and gender identity data with healthcare providers. In a European-wide survey of LGBTI individuals, the EU Fundamental Rights Agency found that 46% of people have not disclosed their sexual orientation or gender identity to any healthcare provider [31]. A lack of trust in healthcare systems may be linked to histories of pathologisation and stigma, and indeed to histories where health systems largely ignored the needs of LGBTQI+ people such as during the AIDS crisis of the 1980s and 1990s.

Not collecting this data makes it impossible to address the health inequalities and disparities that exist for gender and sexual minorities, with the old adage of—if you are not counted, you do not count—ringing true with these groups. In an aim to address LGBTQI+ health inequalities by understanding more about the disparities in health outcomes, the US government issued a directive on collection of sexual orientation and gender identity, and whilst this approach is a useful one in highlighting health needs of gender and sexual minority communities, in many cases individuals are choosing not to disclose, or there is a failure on the part of the healthcare provider in gathering this data [32].

The experiences of discrimination in everyday life, employment, and services add to the stigmatisation and oppression of gender and sexual minority individuals. Compounding this, the experience of discrimination within healthcare can have an even greater impact on health and wellbeing. In a prospective study of LGB individuals and experiences of discrimination in everyday life, almost a quarter of LGB individuals perceived that they received less favourable treatment by medical professionals because of their sexuality [33]. The experience of Trans people can be even further victimising and stigmatising, due to wider unacceptability of Trans identity in society and inability to withhold gender identity in many circumstances [34].

The experiences of discrimination within healthcare are obviously a barrier to build trust and therapeutic relationships with healthcare professionals, and to receive appropriate and culturally responsive care, but may also have a significant impact on health-seeking behaviours. A study by UK LGBT rights organisation Stonewall reported that a 17% of LGBT individuals reported that they avoided healthcare when they needed it due to fear of discrimination [35].

The minority stress model presented by Ilan Meyer [2] highlights three stress processes experienced by sexual and gender minorities: External events and conditions, which in large relates to the direct experience of discrimination and stigmatisation faced by LGBTQI+ individuals; the awareness and vigilance around that discrimination and stigmatisation, being constantly prepared to experience negative responses to sexual identity disclosure; the internalisation of wider discriminatory and oppressive societal attitudes of homosexuality. These experiences of prejudice, expecting rejection, concealing identity, and internalising homophobia in turn can lead to maladaptive coping processes [2]. Although sexual and gender minority individuals may become more familiar with adapting to these stressors over time, the ongoing need to adapt due to external environment can ultimately have further negative impacts on their mental and physical health, as the stress associated with this adaptation persists [36].

The theory provides a useful framework to consider how inequalities related to gender and sexual minority health are complex and dependent not only on internal experiences but also linking these experiences to wider societal conditions. The minority stress model presupposes that the stressors are unique to sexual minorities and not experienced by heterosexual people, chronic (related to social and cultural structures), and socially based [2].

Minority stress theory is a most explicit determination of how wider LGBTQI+ rights can have a significant impact on an individual sexual or gender minority person’s health outcomes. Societal rejection of gender and sexual minority communities can lead to a lack of access to specific services for LGBTQI+ individuals. It further leads to a limitation of social support within a close and more broad social structure—therefore feelings of isolation, stigma, and discrimination become internalised, leading in turn to poor mental health outcomes and coping behaviours which may have further negative physical health outcomes.

Although it has been well established for decades that homosexuality is not an illness, some jurisdictions still pathologise and attempt to ‘treat’ homosexuality [37]. Although clearly repudiated by all major health and human rights organisations, the practice of ‘conversion therapies’ aimed at ‘treating’ or ‘curing’ homosexuality continues, even in jurisdictions with relative societal acceptance and legal protection of LGBTQI+ individuals such as in Ireland [38]. Conversion therapy practice has strong associations with religious beliefs, especially strongly held beliefs that sexual orientations and gender identities that fall outside heterosexuality or cisgender are sinful [39].

As well as being politically unpopular within the human rights community, these conversion therapies can cause actual physical and mental harm to those who experience them, having little efficacy in terms of sexual orientation conversion [38, 39].

With widespread condemnation from human rights organisations, there has been a movement to internationally regulate and ban conversion therapy; however, approaches differ and there are narratives of conflict between banning these practices and religious freedoms [37].

A relatively invisible community within the wider umbrella of gender and sexual minorities are those individuals who are born with intersex variations or differences in sexual development. Intersex variations encompass a diverse set of congenital differences relating to gonads, chromosomes, and genitals that fall outside usual binary views of male and female sex.

Although some intersex people may also identify as Transgender, not all do, and there are very specific needs and experiences shared by these communities. A significant issue for intersex communities is the commonplace surgical interventions which are performed on intersex infants to address anatomical variations [40]. Argued by many, these interventions are cosmetic and not medically warranted, and because they are performed without the consent of the individuals who they are performed on, are equivocal to a form of torture [41]. The long-term consequences of these surgeries are not only physical, and can have wider impacts on the emotional and mental wellbeing of intersex adults—for many of whom the surgeries are kept a secret from them for much of their lives.

It is contradictory that in some contexts where adults face significant barriers to accessing medical and surgical interventions for transitioning to their preferred gender, unwarranted surgical procedures are performed on infants to align them with perceived gender norms.

6. Addressing the healthcare rights of gender and sexual minorities

The right to healthcare is indivisible and interdependent on all other human, civil, and social rights. In order to promote the healthcare rights of sexual and gender minorities, their other rights must be realised in order for them to access healthcare in a safe and appropriate way. Even in a country where there is a right to universal healthcare, this right cannot be realised for gender and sexual minority communities if their other legal and civil rights are not maintained. If healthcare is not appropriate, culturally responsive, and addressing the needs of people then it is not in fact universal. The principles of equality and non-discrimination are key in ensuring that gender and sexual minority healthcare rights are realised.

In addressing the healthcare needs of gender and sexual minority communities there is a dichotomy of approaches which could be taken: either providing specialist and targeted services addressing the communities’ needs based on the health disparities they face, or an approach of promoting LGBTQI+ inclusion within all healthcare services. In truth, a blended approach is most likely to be effective, whereby there are concurrent programs promoting LGBTQI+ visibility and healthcare needs within the main healthcare system, whilst also providing targeted interventions to support LGBTQI+ communities specifically where there are health disparities to be addressed.

The provision of specialist gender and sexual minority healthcare services emerged through community LGBTQI+ healthcare in the USA, whereby LGBTQI+ organisations and clinicians began providing specialist healthcare within their own communities. The provision is clearly linked to political, social, and scientific associations between LGBTQI+ people and health, and the wider needs of the community in gender and sexuality affirming approaches [42].

One significant factor in providing effective healthcare for gender and sexual minority individuals is the need to have confident, competent, and knowledgeable healthcare practitioners, aware of the specific healthcare needs of LGBTQI+ people. For healthcare providers, the gaps in education at both undergraduate and continuing professional development level around LGBTQI+ issues are key barriers to ensuring appropriate care for gender and sexual minorities [43].

Within medical, nursing, and dental students and providers, LGBTQI+ related bias have been identified, and training is a key strategy to reduce this [44]. Whilst there is no definitive and agreed strategy for implementing gender and sexual minority issues within healthcare professional education, an approach that integrates LGBTQI+ issues within both theoretical and practice-focused learning could be beneficial [45].

As with the development and provision of healthcare services discussed above, a strategy which encourages and promotes both inclusion and integration of LGBTQI+ issues within mainstream healthcare education and delivery, as well as prepare practitioners to develop specific healthcare provision is warranted. A framework of ‘Usualising’ and ‘Specifising’ has been developed to ensure both LGBTQI+ individuals are considered in a general way in healthcare education whilst also giving consideration to the specific needs of sexual and gender minority communities [46]. The recommended two-pronged framework suggests that gender and sexual minority identities should be ‘Usualised’ throughout the curriculum, with clinical cases involving LGBTQI+ individuals accessing healthcare as a natural occurrence rather than the primary focus. At the same time, the curriculum should engage in ‘Specifising’ by directly addressing issues related to the specific healthcare needs of gender and sexual minority communities, health inequalities, and interventions to support gender and sexuality affirming care.

7. Conclusion

Undoubtedly there have been significant strides in recognising and protecting sexual and gender minority rights globally, but there is still much work to be done. Discrimination, social stigma, and legal barriers continue to exist in many countries, creating significant challenges for LGBTQI+ individuals. Issues around the health inequalities and disparities further contend that basic legal protections are only one elementary part of ensuring that the rights of sexual and gender minority individuals are realised.

Advocacy and activism have been critical in raising awareness and pushing for legal protections, but continued efforts are needed to ensure that LGBTQI+ can live healthy and well lives, ensuring that all consideration to universal healthcare rights are cognisant of the specific needs of these communities.

Whilst further research on the healthcare needs of gender and sexual minorities is necessary to gain a more comprehensive understanding of their specific healthcare requirements and appropriate interventions, it is important to remember that sexual and gender minority health rights are inseparable from other universal health rights.