Below the Radar Transcript
Episode 148: LGBTQ2S+ Health: Impacts of Stigma — with Travis Salway
Speakers: Steve Tornes, Am Johal, Travis Salway
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Steve Tornes 0:02
Hello listeners! I’m Steve Tornes with Below the Radar, a knowledge democracy podcast. Below the Radar is recorded on the territories of the Musqueam, Squamish, and Tsleil-Waututh peoples.
On this episode of Below the Radar, our host Am Johal is joined by Travis Salway, a social epidemiologist and an assistant professor in SFU’s Faculty of Health Sciences. They’re in conversation about Travis’s research into the impacts of stigma on public health, and particularly the health inequities affecting the queer community. I hope you enjoy the conversation!
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Am Johal 0:44
Good afternoon. Thank you so much for joining us on Below the Radar. Glad that you could join us again. This week. Our guest is Dr. Travis Salway. Welcome, Travis.
Travis Salway 0:55
Hi. Thanks for having me.
Am Johal 0:56
Yeah, maybe we can begin with you introducing yourself a little bit.
Travis Salway 1:01
Sure. I'm an Assistant Professor of Health Sciences here at Simon Fraser University and I've been here, just coming up on two years. I'm a social epidemiologist and my research generally tries to understand patterns of health, that differentially affect what I would call sexual and gender minorities, who would be more commonly known as those who identify as lesbian, gay, bisexual, queer, transgender, or two spirit.
Am Johal 1:31
Travis, as a social epidemiologist whose research investigates population health inequities in the context of stigma, I'm wondering if you can speak about how you got started in the type of research that you do. And then I'll probably move into asking you about the type of research that you're doing now.
Travis Salway 1:52
Sure, yeah. So, my roots are in activism and healthcare response to the HIV epidemic. I came of age in the late 1990s, in California, where I was going to school at the time. And I was struck by how many of the gay men around me were living with HIV, and how many had been really quite passionately involved in fighting for their healthcare rights and social and political rights as gay men and as people living with and affected by HIV. Of course, HIV was neither the first nor the last social or health issue to affect queer people. And so over the years, I made my way through different public health settings, but always with an eye toward, what is it about our social positions and the society around us that makes us susceptible to particular health concerns. At the moment, a lot of my work really focuses on the mental health of LGBTQ2 people. But of course, given the legacy of HIV and given the high rates of HIV in our communities, it's sometimes hard to neatly separate them. And so I still draw a lot of inspiration from the work that I did, looking at activists and looking at frontline workers who were caring for people living with HIV, and we're helping to get out effective relevant HIV prevention tools.
Am Johal 3:25
But first, you know, there's this long history of really important activism in the States. Organizations like ACT UP that you know, strongly influenced communities organizing here around HIV AIDS, but also around drug advocacy, going back to the 90s, as well, and the push around harm reduction to reorient some of these questions of criminalization and stigmatization around a health and human rights orientation.
And now that you are sort of focusing on mental health and stigma, I'm wondering if you can sort of talk about a little bit of the trajectory of these forms of research that you know, begin with a harm reduction orientation. But all of these other structural issues come up in the mode of providing health care or barriers to health that stand in the way.
I know that one of our previous guests we spoke with a few months back was Michael Roberson who has been involved with the ballroom community in New York, working with African American men with HIV AIDS, who were shunned from the church and these sort of communities and the kinship they created through a ballroom and Vogue and other forms of being together in context in which people who were marginalized or didn't have access to health care, or were functioning under processes of stigma.
I'm wondering if you can talk a little bit about your arc of research, how you landed into the realm of, of stigma and mental health in particular as one of the areas that are affecting the groups of people that you're working with?
Travis Salway 5:03
Yeah, I thank you for drawing that connection. I think whether we're talking about community engaged research or community based participatory research or patient oriented research, I think the starting premise is that people, communities, individuals who are finding their livelihood often despite the system. They are the real experts in what's happening in their lives. They're the ones who know what it takes to thrive and be resilient and they're the ones that know where they're bumping up against some of the system's barriers when you're talking about healthcare access or political participation. And so yeah, ACT UP and the history of the ballroom scene.
And a lot of those other legacies are really important to me, because it reminds me that to be able to do the work that I'm doing, and that my colleagues and community partners are doing, there had to be some people who really stuck their necks out and fought hard to have a voice. In terms of mental health.
I think, for me, one of the biggest turning points was, you know, kind of fast forwarding, I guess, about 10 years after I was in Berkeley, kind of first getting involved in the HIV response, I was here in in Vancouver working for the BC Centre for Disease Control, at a time when we were dramatically expanding access to HIV treatment here in the province. And that is widely regarded as a really important public health achievement. We provide HIV medication here in British Columbia for free to anyone diagnosed with HIV. And of course, there are still many barriers to accessing that medication. But that is a significant investment that we've made in our public health care system.
And when I was working at the BC Center for Disease Control, one of the things that really stood out to me was that we had dramatic decreases in HIV related mortality, in some of the more severe outcomes. But at least among my community, among gay, bisexual, and queer and other men who have sex with men, the number of new cases of HIV new infections was kind of remaining steady.
And so I worked with a number of other public health partners with one of my mentors, Dr. Mark Gilbert, and with community organizations and HIV service organizations to try to untangle what's going on around the HIV epidemic, this is back in would have been in 2011 2012. And at that time, one of the academic theories that was kind of getting traction locally, and I think in community groups as well, was this notion of syndemic, S y n demic. So like an epidemic, but instead looking at multiple co occurring health conditions, that first of all, they kind of create an interaction.
So the effects of having both of the epidemics or multiple epidemics is worse than just having one alone. But also, and maybe even more importantly, they were happening in the context of some kind of social or structural disadvantage. So in the case of sexual minority men or men who have sex with men, this was kind of having grown up with a sense of doubt or uncertainty about who we are, and what's our sexuality, and then perhaps struggling to find connection and community around that. And so syndemic theory points to not only the dramatically higher rates of HIV among gay and bisexual men, compared to say, heterosexual men, but also really high rates of substance use, and high rates of mental health concerns, in particular, depression, anxiety, and suicide.
And so I spent my PhD, really trying to come up with a robust epidemiological picture of what's happening with suicide rates among gay and bisexual men in Canada. And we found using a variety of methods that, you know, as of 2008 2009, there were more gay men dying from suicide than were dying from HIV. And that's because HIV, we had invested a lot in treatments to help ensure that people living with HIV have a long life and a healthy life. And we haven't made those same investments when it comes to mental health.
So that was kind of the turning point for me. And since then, I've kind of moved from doing the more, what we would say in my field as descriptive epidemiology, into some more action research. So how do we actually intervene and change policies and change services?
Am Johal 9:37
Yeah, I have two questions for you. One is if you could describe your methodological approach as a researcher and how that shifted over time, particularly in terms of your community engaged research approach. And secondly, once you do have outcomes in the way that you're producing research, how do you view your role as a researcher and how it interfaces with the policy process in terms of government?
Travis Salway 10:06
Yeah, so in terms of methodology, I use what we would describe in public health as mixed methods. For me, the quantitative part of my research in epidemiology is really to help us understand the scope of a problem, how many people are affected, how old are they, where do they live? The kind of bread and butter of our work as epidemiologists is really coming up with a statistical portrait of a health issue. But of course, there's a lot that we cannot know from quantitative methods.
So going back to that example of what turns out to be about four to five times higher rates of suicide in sexual minority adults compared to heterosexual adults, you know, we can only get so far in understanding the nature of that health disparity, if we're using surveys and, and quantitative data sets. We need them to actually sit down and talk to people who are struggling with suicide to understand, you know, what's going on in their lives, what, you know, what are some of the particular factors that might be affecting them, as LGBTQ2 people. And so for me, that qualitative component is really essential, because it allows us to get much richer understandings of the context and the lives of people affected by the issues.
Am Johal 11:26
In terms of your research, do you also break down the work in terms of how socio economic issues or racial or ethnic communities factor into the community site you're working with in terms of differential impacts? Or?
Travis Salway 11:41
Yes, I mean, that's hugely important. We know that intersectionality frameworks are really essential to understanding socially complex phenomenon. And of course, my research sort of starts from a question, what is it about our sexual and gender identities that's shaping how we come to be healthy, or not. I am a white European settler. I'm a university professor, so you know, I have some not insignificant economic and resources around me. And the way I experienced my health, as a queer person, will, of course look very different than someone who is Indigenous, someone who's black, someone who is living under different socioeconomic circumstances.
The way we try to do that is two things. One is, I try to do as much work as possible partnering with, in the case of racial, ethnic diversity, I tried to partner with community leaders who are themselves identifying as BIPOC. And who can actually speak and lead with authority. So for example, I do a lot of work through a group called the Two-Spirit Dry Lab where we, those of us who are not Indigenous, like myself, kind of work in a circle around other Indigenous Two Spirit and Indigenous LGBTQ people to understand what they want the research to look like? And what are the most important issues affecting them? Because toward them, it's not so simple as saying, I want to change this policy or practice to have better equity for LGBTQ2 people. They are also living in bodies where they can't separate their indigeneity from from their sexual orientation or gender identity. And so they may have entirely different ideas or solutions to the problems that we're talking about. So that's an area of work for me. I can't say that I've got it perfect. I try as much as I can to look out for and to listen for those important intersectional differences.
Am Johal 13:41
Now, I know that with some of your colleagues in health sciences, who've been doing research on the Coronavirus, one of the challenges of working epidemiologically is that you're beholden to the public data that's available to you as a researcher. I'm wondering about the area of work that you're doing. Are there some challenges around data transparency, or parts of information that have been difficult to get in terms of doing the type of research that you're doing?
Travis Salway 14:12
Yeah, absolutely. We have a huge challenge as LGBTQ2 health researchers in dealing with both how we find, how do we sample LGBTQ2 populations? And how do we measure and identify them? And when it comes to sampling, we do have some really wonderful studies here in Canada, where researchers like myself have worked with community organizations and, and networks to build trust so that we can go and do what we would call Community Focus Surveys.
But when we then turn to what I suspect you're alluding to, like some of the more public datasets, for example, federally funded surveys by Statistics Canada, or our provincial administrative health data or provincial surveys, we have two problems. The first is, in many cases, the people running those studies didn't bother to ask about sexual orientation, or they didn't bother to ask transgender inclusive measures of gender identity. And so in other words, they've rendered us invisible because they didn't even think about it at the time of doing the study, presumably because it wasn't a priority for them.
But even once they do ask, we have a problem that many of us who are LGBTQ2 are taught early on in our lives to very carefully manage that information about our identity. It's what Erving Goffman would have called a, you know, concealable stigma. For many people you could go out and about in the world and avoid people actually knowing that you're LGBTQ2. And that becomes an adaptive mechanism to protect you from facing harassment or discrimination or violence.
But for us, as health researchers, that becomes a problem because if someone, let's say an interviewer from Statistics Canada calls you up and asks you to participate in a 30 minute survey about your health, and they get to the question where they say, do you identify as lesbian or gay or bisexual, you may without even thinking about it, you may instinctively withhold that information, because there's no benefit for you to tell a stranger this information. And you might perceive a potential harm that if you if you say, "Yes, I'm gay", that person may have a reaction, they may react negatively or surprised, all of which could remind you about negative experiences you've had in the past. That's a really delicate topic.
And we are working on ways to get around that and ways to improve data collection for LGBTQ2 people. But you're absolutely right, that there's a scarcity of data. And that does mean that we sometimes don't have as clear a picture of the health of this population as we might of others that are routinely identified in the census or in other public data sources.
Am Johal 16:58
Given your long involvement in research with these communities, I'm wondering if you can sort of share what you might think as emerging policy areas or emerging areas of research that would have policy implications in terms of what's not already in the public realm, because I imagine, you know, we shift all the time and even the pandemic environment made some situations far more acute or exacerbated accelerated certain processes. We certainly see that related to the drug contaminated crisis in the Lower Mainland, but I'm wondering what you see as emerging related to your own research that has policy implications?
Travis Salway 17:41
Yeah, maybe I'll give you two that are related but different. One really important emerging or at least growing area is how does the healthcare system respond to LGBTQ2 health users or patients in a way that's equitable. And so this means, first of all, are LGBTQ2 people coming forward for health care and support when they need it and some of the data we have. And again, this is limited because of the issues I just discussed. But but some of the data we have suggests that LGBTQ2 people are quite avoidant, that they may not go to the doctor, or they may not go to the doctor as quickly, because depending on their relationship with that doctor, they may fear a negative reaction if that person finds out about their sexual orientation or gender identity.
So as you might imagine, COVID has, in some ways, offered new opportunities for us to address this. There's a lot more virtual care and virtual care means there might be ways for you to connect with a provider who is affirming of your LGBTQ2 identity, who maybe would have been out of reach before COVID, when we didn't have these virtual care options. But on the flip side, it means that for a lot of LGBTQ2 people, they had yet another reason to avoid going in for preventive health care. This is even more pronounced if we talk about transgender people who are needing access to gender affirming care.
And I think we're just starting to get a picture now of what the COVID pandemic has done to people who needed life saving identity affirming health care, but were asked to wait because of precautions related to the pandemic. But I think in the coming years, this is going to become an even bigger topic of focus for myself and for others working in the healthcare system. Because if we want a health care system where everyone has equitable access to preventive care, to prescription drugs, to, you know, mental health services, then we need to understand who is not served by this kind of modal healthcare delivery system. So I think that's an important area of growth.
And then the second thing that I would mention in terms of policy opportunities is to do with something called conversion therapy. So I should probably first define it because it's a bit of a confusing term. So conversion therapy refers to a set of practices that attempt to deny or discourage or dissuade LGBTQ2 people from expressing that identity. The conversion part is an antiquated reference to an attempt on the part of historically psychologists and thereafter unlicensed, often religious or other practitioners who wanted to try to convert someone who deviated from a heterosexual cisgender kind of expectation. They wanted to convert them to being heterosexual and cisgender.
The practices are not effective and they're quite harmful. We see dramatically higher rates of suicide, anxiety, substance use, from people who've been through conversion therapy. And by some surveys, we estimate that as many as 50,000 Canadians have been through it. So it's not an issue of the past. It's a contemporary issue. And for this reason, the federal government in December of 2019, decided that they were going to take a stand on this, they put forward legislation to ban conversion therapy.
That bill, which was Bill introduced as Bill C-8, and then after the COVID interruption, reintroduced as Bill C-6. That bill unfortunately did not make it to the Senate for a vote before this last session of parliament ended. So we do not yet have a federal ban on conversion therapy. But it did bring this issue to light all of the conversations and the media coverage and the House of Commons debates over, should we take a stand on these practices. And I think that was in some ways very painful for people who've been through conversion therapy to have to see their painful experiences debated. But on the on the positive side, it really helped us see quite clearly that the vast majority of Canadians are opposed to these practices, and that they continue to happen in parts of Canada that aren't always visible to us, that they continue to happen without people calling them out or, or identifying them for what they are, is really an injustice to all of us in Canada. And so we now more than ever have an obligation to understand this problem, and to figure out a policy solution to it.
Am Johal 22:22
Yeah, we've had Adrienne Smith as a guest on the show to talk about sort of legal implications and wondering particularly around gender transition surgery and others, there seems to have been historically a patchwork quilt of policies, depending on which provincial jurisdiction, which governments were in power, and, even to this day, significant barriers to access health care. I'm wondering how some of those policies remain a barrier or a site of discrimination in the number of cases?
Travis Salway 22:55
Yeah, absolutely. In fact, for transgender people who've participated in our studies related to conversion therapy, those who have been subjected to conversion therapy, the vast majority of them had that experience because in trying to access gender affirming care, they encountered a healthcare provider who simply outright denied their self determined gender identity, and used conversion therapy as a way of deterring them from transitioning. And those practices, you're right, it really is a patchwork situation.
If you are fortunate enough to live in a part of the country where there is: A, an identifiable primary health care provider, who will ensure that you have speedy, low barrier access to gender affirming care. But second of all, someone that actually has availability, because we know that the wait lists are quite long, then, you know, then that's great. But if you're unlucky enough to, you know, come of age, somewhere where those services are not identifiable, or where those services are completely full, and backlogged, which is unfortunately the case in most of the country, then we actually expose those individuals to a lot of risk. We know, for instance, from the Trans PULSE study out of Ontario, that the highest risk period for suicide for trans people is that period before they get access to gender affirming care, while they're waiting for those really important supports that would affirm their gender identity. So I do think that's a huge area of growth and policy work for us in Canada. And I hope to see a lot more action across the board. I mean, that's where, you know, the provinces obviously have to do a lot of the work in terms of the health care policies and the systems that are in place and funding. But I think there's also work for the federal government to do around setting standards for equity across the country.
Am Johal 24:50
But when you look internationally, policy frameworks with LGBTQ+ communities in terms of those who are really pushing the agenda in terms of progressive policy, and where in the Canadian context we're behind in certain areas, where would you look to where you think that nation states or policy frameworks and other places might give us a place to look to to look at a track record that would be I think, useful here in terms of opening up political space and policy space to build on previous work that activists have done.
Travis Salway 25:25
I love that question, because I think sometimes in Canada, we're stuck with a narrative that because we've passed marriage equality now going on 15 years like we're somehow we're done. We've created an equal society. And we can, you know, call it a day. But when we look around the world, you're right, we see lots of examples of countries that are taking remarkably progressive action in terms of policy and provision of resources.
Unfortunately, there's no one country that seems to be getting it right. But there is an organization called ILGA, the International LGBTQIA Association and ILGA Europe has created something called the Rainbow Index, the Rainbow Index is basically a policy score from zero to 100. And it's scored based on something in the order of 50, or 60 laws or policies that ILGA is aware of that have been used in Europe. And they basically create a map that shades each country, according to how many of those known 60 ish measures have been implemented. And then what you start to see is a lot of geographic variability, as you might expect.
We have some countries, you know, take, for instance, Belgium, that, you know, consistently scores quite high. They've had a lot of LGBTQ affirming policy work. Also Malta, perhaps because of its size, but also a very active and vocal, LGBTQ organizing community there. So you can see that they have created relatively positive and affirming environments for LGBTQ people. And then other countries, take, you know, Turkey or Russia, where we see actually very few protections and even some measures that continue to criminalize or penalize LGBTQ people.
But I think you're right that if we actually look across the board, there's lots of examples of efforts that are being made in other countries that we have yet to explore in Canada. And and I think, when you asked earlier, you know, how do I make sure that that the work that I'm doing the research that I'm doing reaches policymakers, I welcome your advice, because my experience with the conversion therapy bill was that this was very difficult. I think a bill was introduced, and it was thought to be good enough and have the provisions that we needed, and therefore LGBTQ communities should just get behind it. But the reality is, it was missing a lot of really important components that we think are part of an effective conversion therapy ban. And I think that the process through which those of us as researchers, academics, but also the community activists, the process by which we interact with the politicians and their staffers, is really murky. It's hard to figure out the best pathway to get through.
And that's where I hope in the next few years, my team at SFU. And some of our partners, for instance, at the Center for gender and sexual health equity here in Vancouver, are looking to create more tools, very visual tools like the ILGA Rainbow Index Map that will really help policymakers but also everyone, members of the public, just see really quickly, where are we at right now in Canada, or in British Columbia? Or in the Yukon? Where are we at with the policies that we have enacted? And how much farther could we go, if we were to take inspiration from countries like Belgium and Malta, etcetera?
Am Johal 28:53
Travis, is there anything you'd like to add?
Travis Salway 28:56
I think anytime we talk about conversion therapy, or LGBTQ2 equity, I try to make the point that the people that I work the most with, are health care providers and policymakers, but actually everyone, if you're a parent, or you're a sibling, you're a teacher, you're a coach, you're a faith based leader, everyone has a role to play in reducing the threat of conversion therapy and in affirming the lives of LGBTQ2 people. And it's really quite simple. What we need is for everyone to turn to the people that you know, in your life who are LGBTQ2 or the people that you don't know, but who might be internally struggling with some of those feelings and ideas that who you are, who you love, who you identify as, that's valid, and you have a future that can be happy and healthy, whoever you are. And that simple message is quite powerful when it's delivered consistently. I think where we run into trouble is where we have young people who just unfortunately, grew up without ever hearing that message clearly. And then they hold back and they feel like, I must go to conversion therapy, because otherwise, how else will I survive in this society? So it's incumbent upon all of us to make sure that message gets out. So I'm sure your listeners are already sharing that message with the people around them. But clearly we have more work to do as a country in order to get there for LGBTQ2 people.
Am Johal 30:25
Travis, thank you so much for joining us on Below the Radar.
Travis Salway 30:30
Thanks. It's been a pleasure.
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Steve Tornes 30:35
Below the Radar is a knowledge democracy podcast created by SFU’s Vancity Office of Community Engagement. This has been our conversation with Travis Salway. Head to the links in the show notes to learn more about his research.
Stay up to date with Below the Radar by visiting us online at sfu.ca/voce, or following us on our various social channels; on Instagram and Twitter @sfu_voce, or on facebook @sfuvoce. Thanks again for listening, and we’ll see you next time on Below the Radar.
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