HIV Transmission -> What We Know & Why States Are Getting It Wrong


andrew shaughnessy

By: Andrew Shaughnessy, Manager of Public Policy
PROMO Missouri

AIDS.gov states that certain body fluids from an HIV-positive person can transmit HIV.

The body fluids mentioned are: Blood, Semen (cum), Pre-seminal fluid (pre-cum), Recital fluids, Vaginal fluids, & Breast milk.

Nowhere on this list does it mention saliva. Missouri laws, similar to several States, criminalizes behaviors that the CDC regards as posing either no risk or negligible risk for HIV transmission, this includes saliva. The Justice Department goes so far as to detail the best practices States should incorporate to make HIV-related laws align with science.

However, earlier this week, Missouri Legislator Travis Fitzwater (R -49) introduced Missouri House Bill 1181, which would have made it a crime for an individual knowingly infected with HIV to intentionally project saliva at another person.

HB 1181

Missouri is no stranger to strict laws (MO Rev. Sec. 565.085) that criminalize certain behaviors that have been proven by science to not transmit HIV. Several States still reference criminal statutes that fall under this category, which is why States should start modernizing their HIV criminal laws: now. Enacted through the fear of the 80s – early 90s, Missouri, like many States, continues to get it wrong it when it comes to effective HIV/AIDS policy. States enacted these laws with the intention of reducing HIV transmission, however research shows that these fear-based laws have the opposite effect and help HIV proliferate.

Missouri House Bill 1181 was scheduled for a hearing on Tuesday April 7th, but at the last moment was taken off of the docket. This hopefully signals a step in the right direction — but we still have a long journey ahead. Advocates in Missouri and nationwide should continue to monitor any legislation that seeks to further criminalize people who live with HIV.


Ending Exclusions Under Obamacare

Andrew Shaughnessy, Manager of Public Policy for PROMO

By: Andrew Shaughnessy

For the LGBT community health is a complicated matter. It is further complicated when health insurance companies deny or exclude certain forms of coverage that for some are basic health needs. For LGBT folks seeking gender-affirming health care coverage barriers exist at every turn — until the Affordable Care Act. Or so we thought…

Section 1557 of the Affordable Care Act prohibits discrimination on the ground of race, color, national origin, sex, age, or disability under “any health program or activity, any part of which is receiving Federal financial assistance … or under any program or activity that is administered by an Executive agency or any entity established under [Title I of ACA]….” To ensure equal access to health care, Section 1557 also applies civil rights protections to the newly created Health Insurance Marketplaces established under the Affordable Care Act.


Upon researching a complaint raised to us by a Missourian, who qualified and enrolled in a federal marketplace plan, we concluded that exclusions still exist under ACA plans that inhibit transgender patients from getting the basic care they need. Under certain Federal marketplace health insurance plans exclusions have been put in place that state “sex change services and supplies for a sex change and/or reversal of a sex change.”

A real life example of how this affects transgender patients was raised to me, “I had a large cyst on my ovary that had to be removed a several years ago. I hadn’t started transitioning, so my insurance company didn’t blink when I claimed the surgery to remove it. Fast forward to now. If I had the same problem and walked into the doctor’s office with a beard and “male” on my documents, the insurance company can (and would absolutely) deny my claim.”

The State of Missouri’s, along with several states’ ACA exchange, is administered by the federal government and is governed by this rule, however this exclusion is a clear violation of Section 1557. Transgender patients who rely on marketplace coverage for health insurance are forced to censor their own health management for fear that marketplace plans will deem any healthcare on a transgender body excluded from the plan.

I along with the support of hundreds of Missourians requested that the Department of Health and Human Services investigate these claims and make efforts to remedy any claims of sex discrimination in health insurance plans under the Affordable Care Act.

If you are or know someone who is affected, please consider making a request to the Department of Health and Human Services to investigate these claims.

State Work

For Immediate Release- LGBT HealthLink Grades States on LGBT Tobacco Integration

December 10,  2014

For Immediate Release
Dr. Scout
(954) 765-6024

LGBT HealthLink Grades States on LGBT Tobacco Integration

Ft. Lauderdale, FL – December 10, 2014 – LGBT HealthLink today announced the first ever grades for state tobacco programs’ LGBT inclusion practices. The grades, based on a survey of best practices originally conducted in 2013 and updated this fall, represent an assessment of the overall progress each state has made in addressing inclusion, including policies, training, data collection, and community engagement. Grades span from “A” to “F”, with the average across states a “C+”.

LGBT people smoke at rates that are over 50% higher than the general population and experience profound health disparities in both cancer and smoking-related disease. The survey was developed to bring transparency to how successful states are at integrating this disproportionately affected population into their overall tobacco control work.

According to Daniella Matthews-Trigg, Administrator of LGBT HealthLink, “The results of this survey not only illustrate the work that needs to be done, but highlights the impressive efforts by many states. Our hope is that creating a system for comparison will motivate states to adopt as many best practices as possible, thereby improving acceptance and wellness in LGBTQ communities around the country”. LGBT HealthLink is offering resources to each state to improve their grades.

For several years, LGBT HealthLink (formerly the Network for LGBT Health Equity) has been circulating “Identifying and Eliminating LGBT Tobacco Disparities”, a document outlining the best practices for state programs in LGBT tobacco control, and working closely with states to implement them. These report cards are intended to gauge adoption of those best practices at a state level and create a baseline for future work.

The release of the report cards comes just after the CDC’s Office of Smoking and Health recently accepted applications from states for their next five years of tobacco funding. Dr. Scout, Director of LGBT HealthLink, noted that “In order to eliminate the LGBT smoking disparity, we need to make sure the tobacco control community targets us just like the tobacco industry already does.”

Matthews-Trigg emphasized how closely HealthLink is working with states improve their grades, “We are the people providing technical assistance to these states to do this well, so this is really a report card of our work as much as theirs. We look forward to continuing our work with the many amazing state representatives to get these grades even higher.”

View the report cards: www.lgbthealthlink.org/Report-Cards/2014

For more about the methodology and scoring:


 # # #

 LGBT HealthLink, a program of CenterLink, spreads LGBT wellness best practices across state and federal health departments and community organizations. LGBT HealthLink is one of eight CDC-funded tobacco and cancer disparity networks. www.lgbthealthlink.org

CenterLink: The Community of LGBT Centers was founded in 1994 as a member-based coalition to support the development of strong, sustainable LGBT community centers. Serving over 200 LGBT community centers across the country in 46 states. Puerto Rico and the District of Columbia, as well as centers in Canada, Mexico, China, Cameroon and Australia, the organization plays an important role in supporting the growth of LGBT centers and addressing the challenges they face by helping them to improve their organizational and service delivery capacity and increase access to public resources. www.lgbtcenters.org

Conferences · Uncategorized

“It’s Your Time To Shine!” 2014 LGBTQ Youth Regional Retreats Recap

Motivational-Inspirational-Life-Quotes-2243National Youth Pride Services recently hosted it’s 2014 “It’s Your Time To Shine” Regional Retreat series in Detroit, Michigan (Midwest), Columbia, South Carolina (South) and Washington D.C. (East) thanks to sponsors CenterLink, Lambda Legal, 3LW TV, South Carolina Black Pride, Palmetto AIDS Life Support Services and Al Sura. The retreat was designed to uplift, inspire and motivate the black LGBTQ youth communities in a way that had never been done before. Below, the retreat facilitator and participants recap the events of the three retreats.

In 2014 NYPS changed it mission and vision to be MORE uplifting, positive and empowering; to focus on the positive and less of the negative. We believe that people who are self-confident are more willing to help lift others. After All, winners help others win. Many people are looking for hope, and may just not know where to find it or how to get there. “One Shinning Moment” is our nationwide effort to uplift and inspire our target population. There is much to be said about all the negativity in our communities. This video, shown to all attendees, highlights some of the negative opinions about our community, but we feel this is our #OneShinningMoment to come up with solutions and move to the next level.

The goals of the retreats were to make sure each participant would leave the weekend knowing how to:

Live your life on purpose.

Not on “default.” Be Proactive. Make conscious and deliberate choices. When you don’t choose, circumstances choose for you and you are never leading: you are following or catching up—or worse, living in “default” mode.

Utilize your full potential.

Give what you’re doing your best and fullest attention. Be here now. Even if you’re not where you want to be, giving it half of your effort doesn’t move you forward. Master what you have at hand, for the sake of mastering it, and something will shift.

Live in the question.

There is nothing you cannot be, do, or have, so do not impose limitations on yourself. Instead of saying you can’t get there, ask “How can I get there?” Live in the affirmation of possibility rather than the declaration of negativity.

There is always a way, and it is being presented consistently, but you have to live in the question to be on the lookout for the answer.

Learn to say “No.”

To live your best possible life, you need to learn how to say no to the things that aren’t serving you. The best barometer to measure this by is: if it isn’t a “hell yeah” (Yippee, so fun, can’t wait!), then it is most probably a no. If you have to talk yourself into it, it’s a no.

Once you get comfortable saying no, everything becomes a matter of choice. Living a life of choice is a living a life of freedom.

Know your own value.

Others may be more educated, skilled, or talented in one or another area, but there is something magnificent and valuable about what you have to offer this world that, in comparison, is equal.

Do not allow yourself or anyone else to diminish it. You have a learning disability? So did Dr.King, and that’s what makes him the most powerful speakers. Joe Vitale came from homelessness. Look at him now. Stop idolizing anyone else’s gifts and dismissing your own.

The Midwest version (June), the largest of the three, was held in conjunction with FIERCE, a national program working towards LGBTQ youth of color liberation and located at the Allied Media Conference at Wayne State University. Andrew Rahme, attended the Midwest Regional and based on his experiences and interactions during the weekend, actually became a member of NYPS. Here are some of his thoughts on the Detroit even which had a greater focus on community building and activism:

10383485_10203476696491931_6806017940715506034_nCreation, connection, and transformation are the words that come to mind when thinking about the Midwest Regional at the Allied Media Conference (AMC). Being a queer or trans person of color, it is reality that you have to constantly create solutions for yourself in order to live happily, and successfully. We create walls, stories, identities, spaces, and sometimes we even create realities different from the ones that we are confined to. At the AMC networking gathering, we had a chance to come together as QTPOC and identify the current issues to implement change in our community. Through games, laughter, relationship building, and amazing food, we discovered things about ourselves and about each other that allowed us to grow in ways we didn’t expect.

A very large focus of the network gathering at AMC was surrounded around connection. Connection to each other, to the world around us, and to our personal selves. We mapped out where our interests of change are and brainstormed what steps we can take to implement that change. We connected in ways we didn’t expect through common interests, experiences and the sharing of our wants, needs, hopes, and realities. Many of us began combining different realities and solutions in order to produce ideas for the most effective change.

The end result was inspiring and truly transforming. We got to be first hand witnesses of the beauty that comes out of organizing with QTPOC youth. Ideas as well as lasting relationships were created and strengthened, and to see what change these new alliances will create is exciting to watch for.

The South version (August) was held in Loft’s at The Claussen’s Inn. On Friday night all participants watched the video on the State of The Black LGBTQ Community. Some in the room agreed with some of the statements made, but the majority felt that there were some things that could be done to change the perception of what it is like to be black and LGBTQ.

On Saturday, the first session focused on a common theme in the video: “Status Anxiety”. This is the constant comparing of yourself to others. We looked at how the people you surround yourself with can be stressful and a few ways to get rid of status anxiety. Other issues touched on were: “Later Never Comes” (procrastination), Self Respect, Self Esteem, How Not To Care What Others Think About You as well as our other Life Development Series for Black LGBTQ young adults: “Dollars and Good Sense” and “Born To Win”.

Brandon Berry, of Orlando, FL gives his thoughts on the south retreat:

Brandon Dykes served as a facilitator for the South Region Retreat, as did Brandon Berry.
Brandon Dykes served as a facilitator for the South Region Retreat, as did Brandon Berry.

It was the epitome of comfort, which was a pleasant surprise to me. Imagine walking into a beautiful inn, rich with its area’s history and augmented tall ceiling including a large glass window clearly displaying the beautiful sky. Imagine a two-story loft for a room with all of the space necessary for yourself as well as any of your guests and fellow attendees. One would think no real productive work would be done. Contrary to that thought, we spent a majority of our days with each other having deep, lengthy and intelligent conversations. One of the highlights of this weekend is that great work took place in the comfort of our own rooms. It was a great experience.

I not only met strong and intelligent Black men of distinction, but I got to get personal with them and discuss life and goals and our journeys to our respective unfolding greatness. We held discussions on how to be an effective leader, things to remember when inheriting a leadership position from someone else, and other miscellaneous subjects like the Quality of Education from HBCUs vs PWIs.

Overall the conference was great, and the experience was even greater.

The East version (September) was held at the Akwaaba, a luxury, African inspired house in LGBTQ friendly DuPont Circle. Like the south version, on Friday night, participant’s gathered to watch the video and discuss it. They were more aggressive in their defense of the black LGBTQ community and pointed out how no one in the video took any personal responsibility.

The East Region participants, not only went over all of the same Life Development series topics covered in the South Region, they were able to

Jabbar Lewis facilitated the "Selfies" series in DC.
Jabbar Lewis facilitated the “Selfies” series in DC.

preview parts of our new series: “Choices”: Whether you believe it or not, everything up to this point in your life that has or has not happened to you is because of the choices you have made. Every aspect or our life when examined a little closer can be traced back to a series of choices we have made.

In addition, each participant was given a section of each series to study and then present to the group.

The East Region allowed participants to live together for 3 full days in a fully furnished house, similar to a reality show. This dynamic might have made the East Region one of the best experiences out of the three, so much so, we are looking to hosts future retreats in a luxury house setting. The South and East Regions are also where we tested out having each participant follow each presentation on their tablet/laptop or mobile devices instead of the traditional power points and projectors. They now will be able to relive each session on their mobile device at any time.

Here is a  complete list of all Life Development topics, related videos and handouts from the retreats.

Tobacco Policy

Missouri Coalition Pushes State to National Leadership on LGBT Health

Missouri might not top many LGBT people’s lists of great places to live, but after today you might want to rethink the charms of the Show Me State. For the last year a local coalition has been pushing adoption of LGBT-welcoming policies at hospitals. In this week’s release of HRC’s Healthcare Equality Index, Missouri zoomed from 37th in the country to sixth in the number of local LGBT leader hospitals.

We don’t see policy changes this quickly very often, especially when they require many companies to adopt new policies. What’s the secret to this unlikely success? A few years ago Missouri Foundation for Health funded a partnership with the local Equality Federation partner, PROMO, and SAGE Metro St. Louis. My project, LGBT HealthLink, was also brought on board to provide them with technical assistance. With funding and staff and policy expertise all in place, the Missouri team got down to business to see what they could change to affect LGBT health disparities in their state.

If you just look at the situation today, you’d think they immediately stumbled on the equivalent of oil and a match for policy change, but, like many good projects, they started slowly. First they mapped the policy environment; then they tried a few different strategies for change. One of the things they identified was a big gap: While most hospitals were required to have LGBT-nondiscrimination policies by the agency that accredits them, they could find little evidence of those policies by searching. And if we can’t find them, then patients couldn’t either.

For a while the PROMO staff played nice with the hospitals, trying to build relations and seeing how to move the changes gradually. Some hospitals did respond, but the work was crawling forward. Eventually, we switched to a different tactic, blanketing many hospitals with letters pointing out that these policies were required. Then, of course, the PROMO staff person, Andrew Shaughnessey, was there following up with multiple phone calls offering to help them with policy resources. The new strategy, which we’ve taken to calling the “terrier approach,” worked. Eventually even the hospitals that said they weren’t interested started to call Andrew back. And if they needed LGBT-cultural-competency training as part of the new policy changes, Sherrill Wayland from SAGE was ready to step in to set up in-person trainings at a moment’s notice.

The upshot of all of this work was that, while in 2013 seven hospitals had LGBT-nondiscrimination policies in place, now 31 do. While seven hospitals protected LGBT status in employment, now 30 do. While two had achieved Healthcare Equality Index leader status in 2013, now 19 have. Today several of those hospitals are putting out their own press releases lauding their LGBT-welcoming policies. It’s a far cry from 2013, and that means much better access to health for thousands of LGBT people in Missouri.

What I want to see now is this amazing level of success replicated. I’ve worked in policy change for a very long time, and trust me, a model to change policies this fast comes extremely rarely. While they had a funder in Missouri giving them the time to experiment with different strategies, any other community center or equality organization in another state can take advantage of that work and just do what worked for them. Nicely, the PROMO team has documented their steps really clearly in the LGBT HealthLink blog. See the first post about it here.

Kudos to everyone in Missouri. From the amazing staff team at PROMO and at SAGE to Missouri Foundation for Health, who cared enough to invest, and the many hospital systems who jumped on board, this is an amazing job by all, and it’ll really affect the health of the LGBT communities in your state.

Now who else wants to do it for their states?

LGBT Policy · Show Me MO · Technical Assistance · Updates

Missouri Case Study 10 – Making LGBT Health Matter in Missouri Hospitals

Andrew Shaughnessy, Manager of Public Policy for PROMO

Andrew Shaughnessy
Manager of Public Policy, PROMO Missouri

This year has proven to be a monumental year for LGBT Missourians. Those monumental steps have been the recognition of out-of-state marriages by the State of Missouri, and the leadership of nearly 47 Missouri hospitals, who have included 105 new LGBT welcoming policies to their core values. As an LGBT Missourian it certainly gives me relief to know that I can access health care facilities and be me: my authentic self.

In 2013, only two Missouri Hospitals, Children’s Mercy in Kansas City and the VA in St. Louis, qualified as leaders in the Human Rights Campaign Care Equality Index (HEI). In the coming days the health sector will see the launch of the 2014 HEI, where several of Missouri’s top hospitals have been reviewed on their lesbian, gay, bisexual and transgender (LGBT) welcoming policies.  This year, Missouri will see several hospitals both in rural and urban areas that have been working to ensure their facilities are welcoming to all.

To learn more about the policies of Missouri Hospitals, click here for a map detailing their LGBT welcoming policies.

We have truly made LGBT health matter among Missouri’s top hospitals, but the work of the LGBT health policy project does not stop there. Through the technical assistance of Dr. Scout, Director of LGBT HealthLink, we will continue to work with health and social services organizations in Missouri to ensure that we are creating spaces free from discrimination. Through our collaboration with Sherrill Wayland, Executive Director of SAGE Metro St. Louis, we will be training Missouri’s health and social service professionals to understand the unique needs of LGBT patients.  And we will continue to advocate for the health of LGBT families and our families of choice.

As we begin to look at the legal future for the LGBT community, we must be concerned with the growing disparities we find in LGBT health. Our next frontier is on the borders of health and making sure that we are a strong and healthy community. I’m humbled to be a part of this work. Having experienced discrimination in a health care setting myself, I assure you your voice is not going unheard.



Trans First World Problems

Pride Center Staff Photo


Bishop S.F. Makalani-Mahee

Minister. Performing Artist. Community Organizer





So I’m sitting in  this workshop at Philly Trans Health Conference entitled “Everything in Africa is Gendered”  given by  a south African trans woman of color, and before the workshop even begins she comes over to me introduces herself and tells me that she is living and working in rural South Africa as an out trans woman of color.  I am immediately sobered by the courage of her reality and share my thoughts as such with her; and her response to me was somebody’s got to do the work for those who come after her, so why not her and what I got in that moment is that as difficult as navigating a transgender experience in America can be, I am grateful to be doing so.


I and most of the trans folk I know have access to services like mental health and medical services, we have access to education, and most of us have access to food and community.  While our sister’s and brother’s in developing countries struggle to simply eat, find language that speaks their truth,  experience boundaries to accessing competent and lifesaving  medical  care, limited (if any) education, and they may not  have community for support.  Those of us that are employed, have access to care and community resources (like the ability to attend Philly Trans Health) may want to consider that we have trans first world problems and I would offer that we bare this in mind when wanting to fall out with each other or want to go to battle over things that really don’t matter; like young trans folk thinking older trans folk are stuck in the past and just “don’t get it”.


I would offer instead that we remember that there are trans people who wish they had other’s to relate to; and as we fight amongst each other about setting a trans agenda there are trans folk in our world just trying to stay alive.   We should find ourselves extremely grateful for what we have and the community we have, and if we recognize that even given the work yet to be done we are in a unique place of privilege that other trans people would perceive as the promised land, and we have a responsibility to do the work so that those that come after us have a promised land to enter into.


Continue To Walk In The Light, Redefine Your Faith, and Remember It’s All The Rhythm.


E-Cigarettes: Friend or Foe for the LGBT Communities?


 As published on Huffington Post’s new LGBT Wellness blog, see original at: http://www.huffingtonpost.com/scout-phd/e-cigarettes-friend-or-foe_b_5024583.html

Working in tobacco control sometimes elicits interesting reactions from people. Some try to hide their smoking. While I certainly appreciate not being near the smoke itself, I’ve got great empathy for smokers. In fact, since most smokers have already tried to quit, they’re much more likely to be fellow fighters against tobacco than non-smokers. Sometimes they ask me how to best quit and I’m happy to tell them (hint, call 1-800-QUITNOW). These days everyone’s asking me something new: What about e-cigarettes? The shortest answer is “they could be helpful for a few, but we all worry about our youth.”

First, if you’re not familiar with e-cigs, they are battery-powered imitators of old-school cigarettes, designed to deliver nicotine, flavor and other chemicals through vapor inhaled by the user. Most of them have a swag little electronic light at the tip to make it seem more like an old-school cig. Some now have other names like e-hookah to avoid any cigarette associations. The claim is here’s a no-combustion device to get your nicotine fix, great for cessation and great to smoke in places where cigarettes are banned.

There is one study supporting the effects of e-cigs in helping people quit smoking but now another study is out contravening it. Considering how toxic cigarette smoke is, we all applaud anything that helps reduce the amount of cigarette smoke in the air. But if you’re trying to use e-cigs as a cessation device it’s a bit dicey right now because they’re unregulated, so the amount of nicotine you get in each dose varies, and sometimes does not match the advertising. It’s commonly known that it only takes about two weeks to kick the nicotine addiction of smoking, but anyone who’s quit will tell you, it’s the social habit of smoking that draws you back again and again. I’m not sure how putting a cigarette replacement in your mouth helps you kick that social habit — sounds to me like it’s just perpetuating it. Plus there is a new study showing other toxic chemicals in the vapor. To top it off, there’s no real science on the long-term effects of inhaling nicotine vapor. So while I’m willing to bet it’s better than inhaling tobacco smoke, that’s like saying I bet it’s better than inhaling truck exhaust. Nicotine is so toxic, poison control centers just issued an alert about high numbers of calls on accidental exposure. Just touching the liquid is enough to cause vomiting and ingesting as little as a teaspoon of some of the liquid nicotine concentrations can be fatal. I hope people set a higher bar for their own cessation journey.

The real problem is, as anyone who’s visited a vaporium can see, it’s not a cessation game. Vaporiums and e-cigs are all about enticing, and particularly enticing young people. Wander into your local vaporium belly up to the “bar” and you’ll be shocked to see how many vaporiums look like the lovechild of a hip coffee shop and a candy store. I’m not sure exactly which adult Marlboro user would switch to cotton candy flavored nicotine cartridges, or banana nut bread, or cherry limeade. Sounds to me more like flavors I’d find at a little league game. To make it worse, these products are easily available online and many states aren’t yet doing anything to restrict access to minors. Data show LGBT youth continue to smoke at rates much higher than their non-LGBT counterparts and the number of youth experimenting with e-cigs is rising rapidly… the very last thing we need is to have some fancy new gadgetry on the market enticing LGBT youth to start using a highly addictive drug to deal with the stress of stigma against us all.

We pass on smoking down through the LGBT generations socially. I’ve always called it an STD for us, a socially transmitted disease. So I also worry about adult e-cig use. Every time you “light up” you’re perpetuating the huge LGBT cigarette culture, all of us laughing and having fun and hanging out, with cigarettes in our mouths.

We already have cessation aids that deliver you nicotine in controlled regulated doses, you can find those on every drugstore shelf. Nicely, there’s not one gummy bear or watermelon flavored nicotine patch, spray or gum. So while e-cigs might help a few in quitting, I say the big picture on e-cigs for the LGBT communities is we need to think of our youth and “beware of the wolf in sheep’s clothing.”





 Dr. Scout, Director

 The Network for LGBT Health Equity



Follow Scout, Ph.D. on Twitter: www.twitter.com/scoutout

LGBT Policy

Queer Health, Part III: Our Selves, Our Community


Corey Prachniak is an LGBT rights, HIV policy, and healthcare attorney. He serves on the Steering Committee of the Network for LGBT Health Equity and tweets @LGBTadvocacy.  Views expressed herein are solely those of the author.

 Part I and Part II of this series were published previously.


Over the past few weeks, I’ve argued that even as LGB (and sometimes T) rights are mainstreamed, LGBT people will remain sexual minorities, especially if one’s needs or identities (e.g., identifying as poly amorous, gender-nonconforming, etc.) make one queer or a “deviant” even by today’s standards.  I’ve also argued that the major legal victories of the past decade – most notably, same-sex marriage – will improve the well-being of those whose situation, needs, and privilege allows them to take part, but will not help everybody, and will not directly end health disparities for any of us.

The fundamental problem is that the mainstreaming of “gay culture” has not been a matter of societal acceptance of the LGBT community’s diversity, but rather a reluctant allowance for LGBT people to conform to existing norms.  Those of us who are queer and do not want to obey these gender and sexual norms are not only left out by this process, but are in fact harmed by being turned into ever more ignorable outcasts.  And even LGBT people who identify with mainstream gender and sexual norms will not see health disparities end because of basic differences in LGBT personal health.

So, what will help end disparities – for queers and radicals, and more mainstream folks, too?  There are two types of solutions: those we can tackle as individuals and those we must address as a society.

What can we do as individuals?

The “coming out” of millions over the past several decades has made the LGBT population more visible and less vilified.  Now, those of us who remain on the margins need a new, queerer coming out.  Only if we stand up and are counted will our diversity to be known and understood, if not celebrated, by healthcare providers, insurers, researchers, and policy-makers.

The most direct path to improving our individual health is to come out to our doctors.  In an ideal world, if our doctor are unwelcoming or  unknowledgeable, we could find a new one.  But in reality, not all of us can dump our doctor and select another, and we often have to help educate providers on LGBT needs – one study found 50% of transgender people had to teach their doctors about transgender health.  We also have to know our rights so that we don’t let providers get away with treating us in a way prohibited by law.

But beyond coming out to providers, we need to come out as queer across our social spheres, with the goal of being better understood rather than pushed further to the margins.  If we are tactful, the conversations we have every day will shape our personal relationships and in the aggregate move society.  We need to share why we don’t want to identify as male or female, or don’t want a monogamous relationship, or don’t want to limit our attraction to just one sex.  We need to claim the power to identify as we see fit, and not to let someone else tell us at what point we “change” from being a boy to being a girl.  We need to fight against the dominance of traditional social structures whose defenders seek to elevate their moral standing above “alternative” lifestyles while ignoring the Millennia of violence, subordination, and hypocrisy by which their traditions have been marked.  And we need to do all this – to fight the dominance of mainstream social structures and identities – without fighting their legitimacy as an option for LGBT people who would associate with them.

Whether or not you relate to queer identities or are LGBT at all, you have a role to play if you wish to be an ally.  You can be receptive when someone else expresses their identity as queer, non-conforming, transgender, or bi.  You can be sensitive to the fact that some queer people have different legal, social, and healthcare needs than you.  And remember: even if you identify as gender-conforming, straight, and monogamous, having the option of an alternative-but-accepted identity will increase your liberty, too.

In his seminal work The Trouble with Normal, Michael Warner argues that LGBT participation in the institution of marriage is not “simply a choice [or] a right that can be exercised privately without costs to others…  Even though people think that marriage gives them validation, legitimacy, and recognition, they somehow think that it does so without invalidating, delegitimating, or stigmatizing other relations, needs, and desires.”  I would not suggest that same-sex couples refrain from marrying on principle if they’ve considered it seriously and face legitimate disadvantages if they abstain.  However, I agree with Warner’s point that by participating in mainstream institutions and identities, LGBT people risk legitimizing them at the expense of others.  It sends a message that some relationships and identities deserve more recognition and protection than others, and thus must be better, causing stigma and psychological harm.  It takes the pressure off lawmakers to offer rights, protections, and services to people who don’t benefit from existing structures.  And it perpetuates the perception that some people are normal and some are deviant, even if “normal” can now include certain well-behaved gays.

Make the best choices for you and your health.  But balance that self-interest with compassion for those in our community whose needs are different, and remember that same-sex marriage isn’t the end.

What can we do as a society?

While there is no set of policies that can end health disparities overnight, there are many ideas we should consider moving forward.

  • We should find ways to recognize families of choice rather than perpetuate the elevation of married households above all others.  We can do this by having domestic partnership laws that allow people to define their relationships themselves.  DC’s domestic partnership law allows any two people to register, even outside conjugal couples.  Even this law could be improved by opening it up to more than two people and increasing flexibility.  And the package of rights available in such partnerships – e.g., to provide health insurance to a partner, to make medical decisions if a partner is incapacitated, and to extend legal immigration status – should be as extensive as married couples enjoy.  At the same time, these agreements should be choices and not social necessities that merely take the place of marriage.
  • We should formally ban discrimination on the basis of sexual orientation and gender identity by anyone providing healthcare, insurance, or related services.  The Affordable Care Act, for the first time in history, bans healthcare discrimination on the basis of sex, race, national origin, age, and disability.  Currently, the Department of Health and Human Services is considering how “sex” should be defined.  If interpreted fairly, it will include gender identity and sexual orientation.  If not, we need to push for healthcare nondiscrimination laws so that LGBT people can get the care they need without fear of mistreatment.
  • We should require insurance policies cover the services necessary for transgender people who are currently denied through outright discrimination or on the basis that they are “cosmetic.”
  • We should explore how to make sex work safe regardless of its legal status.  LGBT people make up a disproportionate share of sex workers, who under current law are abused and prevented from having the bargaining power to demand safer sex practices.  Ending stigma and financial uncertainty will also make it easier for sex workers to seek medical care.
  • We need to increase access to mental health care so that those in the LGBT community who face stigma, abuse, and discrimination can get the care they need.  Additionally, we need to stop stigmatizing people who take responsibility for their health and utilize these services.
  • We need to support LGBT people as they age.
  • We need sex education for people of all ages that is inclusive of the needs of LGBT people.
  • We need to fight against tobacco and alcohol companies that target LGBT populations.
  • We need researchers, healthcare providers, and government agencies to include gender identity and sexual orientation in the data they collect, and to use that data to end disparities.
  • We need to invest more money in finding solutions to health problems that affect LGBT people, especially HIV/AIDS.
  • We need to stop criminalizing people living with HIV and start supporting them.


The freedom to enjoy good health is a human right, and one that is unfairly hindered for many minority populations.  Our health is so essential to our selves that there is no part of our life that it does not affect, and that is not affected by it.

The fight for our health is thus a fight for our selves, but also for our community.  However we find and define our queerness as individuals, we deserve to live, and to live well.  By challenging norms instead of bowing to them, we can ensure that no one is left behind in the struggle for health equity.

Special thanks to Rodrigo Aguayo-Romero for his help editing this piece.

LGBT Policy

Queer Health, Part II: When Trickle-Down Equality Isn’t Enough




Corey Prachniak is an LGBT rights, HIV policy, and healthcare attorney. He serves on the Steering Committee of the Network for LGBT Health Equity and tweets @LGBTadvocacy.



 Part I of this series can be found here.

As marriage and workplace equality pick up steam, some LGBT people and their allies think the fight is almost over.  The data tells another story.  At most, the marriage movement delivers trickle-down equality in terms of queer health, with folks benefitting less and less as one moves towards the fringes.  If it is justice that we seek, this cannot be enough.

Marriage and workplace equality can relate to health disparities in one of three ways: (1) direct impact, (2) indirect impact, and (3) no impact at all.

1) Are there any health disparities that will be directly diminished by marriage and workplace equality?  The short answer is “no.”  Instead, these advancements in the law will only directly impact the disparity in rates of health insurance.  To be sure, many LGBT health disparities are exacerbated by the fact that LGBT people on the whole are less likely to be insured.  Marriage equality will extend opportunities for some same-sex spouses to get covered and workplace nondiscrimination laws will prevent people from getting fired and losing employer-sponsored insurance.  But these are all indirect effects on actual health disparities.

Furthermore, increased access to insurance doesn’t change the behavior of insurers or medical providers in a way that would make them more responsive to LGBT needs.  Rather, increased rates of insurance only opens up the existing, status quo healthcare market to more LGBT people.  While this should not be overlooked as an accomplishment, it must be recognized as access to a broken system and not systemic change.  And those who are already insured will not benefit at all from this development.

2) What health disparities are indirectly affected by these advancements?  The changing legal landscape for queer people can have an indirect effect on health disparities in one of two ways: by changing the behavior of medical providers, and by changing the behavior of LGBT people themselves.

What medical practices might change?  Over time, the mainstreaming of certain LGBT people will likely make medical professionals more comfortable with LGBT patients.  This should mean a decrease from the 8% of LGBT people who a few years ago stated that they had been directly denied care for being LGBT, as well as the countless others who received some kind of disparate treatment.

However, marriage equality won’t necessarily make providers more comfortable with queer people disinterested in adapting a mainstream gender identity, orientation, or relationship structure.  Providers today might treat with less hostility a gay man who has a partner and a child, but might not be more inclined to show respect for a genderqueer person in a polyamorous relationship.  With about a quarter of transgender and gender-nonconforming persons reporting direct discrimination in healthcare, the folks with the greatest health disparities stand to benefit the least from the marriage movement.

Furthermore, greater acceptance of mainstream gay culture could backfire against queer sexual minorities: some providers might believe that now that gay people can get married, there is no reason for a patient to be promiscuous or not conform to a “normal” gender identity.

This backfire could also occur with well-meaning providers who already deliver substandard care to LGBT patients because they aren’t aware of queer health disparities.  Normalizing same-sex marriage may lead well-intentioned providers to even further presume that the needs of the LGBT community are the same as those of everyone else.  They’re not.

What LGBT behavior might change?  It is even less clear that recent legal wins will lead to LGBT behavioral changes that will decrease health disparities.  Sexual health disparities among LGBT people are tied in with ever-changing notions of what is “safer sex,” a term that acknowledges the fact that no sexual act is objectively either entirely safe or entirely unsafe.

The availability of same-sex marriage may make more LGBT couples aim for monogamous, long-term relationships.  But that does not necessarily mean safer sex.  In fact, people in long-term relationships are less inclined to use safe sex equipment (e.g., condoms or dental dams) because of the presumption that they are sexually active only with each other and therefore not exposed to disease.  However, much of the spread of HIV – particularly in the heterosexual community – is within married couples, in which at least one partner is having extramarital sex and the other partner lacks the bargaining power or knowledge to request the use of safer sex practices.

In fact, the entrenched power dynamics and gender roles of the marriage framework have long had a negative effect on health.  Historically, the system of marriage has been used to prevent women from being economically dependent, often forcing them to trade control over their bodies for financial support.  Even today, there is disbelief among some that a man can be guilty of raping his wife since he is entitled to have sex with her.  Congressional Republicans have made attempts to limit the definition of rape to that which was “forcible,” while a current congressional hopeful recently made headlines for claiming that a woman should never be able to file rape charges against her husband.  (To be sure, marriage also offers certain legal protections, such as a right to shared resources, that could protect some same-sex partners from abuse.)

Additionally, changes in same-sex relationships may decrease disparities in alcohol, tobacco, and drug use because the mainstreaming of LGBT life has led to a decreased need to use bars, clubs, and parties as a way to gather and meet.  But not everyone will choose to get set up by their pastor and never enter a club again, and even those who do will still face other factors that lead to substance abuse, such as LGBT-targeted ad campaigns by alcohol and tobacco companies and the mental health stress of being a sexual minority.

So it remains an open question as to whether allowing same-sex couples to marry will decrease or increase safer sex behavior, as well as whether it will decrease or increase intimate partner violence and substance abuse.  It seems certain that it is not the best way to work towards improving these health disparities, and that transgender, gender-nonconforming, and nonmainstream queer people have the least to gain from any potential changes.

3) What health disparities will definitely not be improved by recent legal victories?  There are some health disparities that result from inherent differences between the LGBT population and the rest of society.  Because HIV is more easily transmitted to a receptive sexual partner, and because heterosexual cisgender men do not (as a group) have receptive anal sex, there will always be higher susceptibility among gay men, bisexual men, and transgender women.  Similarly, this population will always have an increased risk of anal cancers.

Lesbian and bisexual women have been found to be at greater risk of breast and cervical cancer than the female population in general, and this is at least in part because of inherent differences in sexual practices.  Same-sex marriage may lead to more lesbian and bisexual women giving birth, which could decrease the risk of some cancers.  But we can presume that the birthrate among women having sex with women will always remain lower than heterosexual women, so there will always be disparities.

Society’s general movement towards qualified acceptance of the LGBT community will hopefully lessen the mental health disparities among LGBT people.  However, as people become comfortable with the idea a same-sex couple getting married, that will not necessarily help a young a person who identifies as transgender, or who identifies as neither male nor female.  It will not help a child whose parents tell her that she can date another woman if she wants, but not a transgender boy she met at school.  It will not help a person whose boss would be fine knowing that he has a husband, but not knowing that he lives with a male and a female lover with whom he collectively raises a child.

Besides, some mental health disparities are partially the result of physical health disparities.  For example, the stigma that comes with being HIV-positive can cause great stress, so as long as the LGBT community remains more at risk for HIV infection, and as long as there is stigma attached to it, LGBT people will be more susceptible to this particular mental health strain.

And because same-sex marriage only has a marginal legal effect on the transgender community, and transgender people are most likely to be left out of nondiscrimination laws, their health disparities will be least relieved by recent legal developments.  Greater access to healthcare insurance still would not help transgender people whose plans have broad exclusions of “transgender-related care.”

So, what do we do?  It stands to reason that if we care about justice, we should focus our energy on those who face the greatest injustice.  The marriage movement has not done that – at least not with respect to health, which is the most basic aspect of our dignity as humans.  Instead, those with the greatest disparities – queer people whose gender identities, orientations, and sexual practices remain outside the mainstream – have been helped least of all.

We cannot be content to wait for the benefits of the marriage movement to trickle down and help those at the “bottom” of the social ladder.

Part III will suggest a new path forward.