Colpitts and Gahagan BMC Public Health (2016) 16:1005
DOI 10.1186/s12889-016-3675-8
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RESEARCH ARTICLE
Open Access
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“I feel like I am surviving the health care
system”: understanding LGBTQ health in
Nova Scotia, Canada
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Emily Colpitts and Jacqueline Gahagan*
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Abstract
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Background: Currently, there is a dearth of baseline data on the health of lesbian, gay, bisexual, transgender, and
queer (LGBTQ) populations in the province of Nova Scotia, Canada. Historically, LGBTQ health research has tended
to focus on individual-level health risks associated with poor health outcomes among these populations, which has
served to obscure the ways in which they maintain their own health and wellness across the life course. As such,
there is an urgent need to shift the focus of LGBTQ health research towards strengths-based perspectives that
explore the complex and resilient ways in which LGBTQ populations promote their health.
Methods: This paper discusses the findings of our recent scoping review as well as the qualitative data to emerge
from community consultations aimed at developing strengths-based approaches to understanding and advancing
LGBTQ pathways to health across Nova Scotia.
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Results: Our scoping review findings demonstrated the lack of strengths-based research on LGBTQ health in Nova
Scotia. Specifically, the studies examined in our scoping review identified a number of health-promoting factors
and a wide variety of measurement tools, some of which may prove useful for future strengths-based health
research with LGBTQ populations. In addition, our community consultations revealed that many participants had
negative experiences with health care systems and services in Nova Scotia. However, participants also shared a
number of factors that contribute to LGBTQ health and suggestions for how LGBTQ pathways to health in Nova
Scotia can be improved.
Conclusions: There is an urgent need to conduct research on the health needs, lived experiences, and outcomes
of LGBTQ populations in Nova Scotia to address gaps in our knowledge of their unique health needs. In moving
forward, it is important that future health research take an intersectional, strengths-based perspective in an effort to
highlight the factors that promote LGBTQ health and wellness across the life course, while taking into account the
social determinants of health.
Keywords: LGBTQ, Health, Canada, Health promotion, Health research, Health measurement
Background
Currently, there is an absence of baseline data on the
health of lesbian, gay, bisexual, transgender, and queer
(LGBTQ) populations in the province of Nova Scotia,
Canada. Studies from other regions of Canada (Ontario,
British Columbia, and Quebec), as well as the United
States and the United Kingdom suggest that the health
* Correspondence: jacqueline.gahagan@dal.ca
Gender and Health Promotion Studies Unit, School of Health and Human
Performance, Dalhousie University, Stairs House, 6230 South Street, P.O. Box
15000, Halifax, NS B3H 4R2, Canada
of LGBTQ populations is worse than that of their
heterosexual, cisgender age-matched peers [1, 2]. Given
that Atlantic Canada, including Nova Scotia, tends to
have worse health outcomes than other regions in
Canada [3], the dearth of data specific to LGBTQ health
in Nova Scotia is of particular concern. For example, in
comparison with the national average, Statistics Canada
data indicate that Nova Scotia has higher overall rates of
obesity (60 % versus 52 %), arthritis (26 % versus 15 %),
diabetes (8 % versus 6 %), high blood pressure (21 % versus 17 %), chronic obstructive pulmonary disease
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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(COPD) (6 % versus 4 %), colon cancer (60 % versus
50 %), heavy drinking (20 % versus 17 %), lung cancer
(54 % versus 45 %), and a lower rate of functional health
(77 % versus 81 %) [4]. Although these data are important in advancing our understanding of the overall health
conditions impacting the health of Nova Scotians, they
do not specifically refer to the health of LGBTQ populations in Nova Scotia.
Conducting LGBTQ health research in Nova Scotia is
critically important given that LGBTQ health needs have
historically been understood through a heteronormative,
gender-binary lens, which assumes that the health needs
of LGBTQ populations are similar to those of their heterosexual, cisgender age-matched peers [2, 5, 6]. This
heteronormative and gender-binary approach to LGBTQ
health has effectively rendered the health needs and experiences of these populations invisible within mainstream health care systems, health data, and health
policies [6, 7]. The invisibility or erasure [7] of LGBTQ
populations and their specific health needs and lived experiences hinders the provision of evidence-based, culturally competent health care for these populations.
Previous health research from projects conducted outside of Nova Scotia demonstrates that LGBTQ populations experience significant discrimination and stigma
within health care systems based on the heteronormative
and gender-binary framing of health [8, 9]. For example,
Goins and Pye [9] found that the heteronormative and
gender-binary language and structure of medical intake
forms have the consequence of alienating LGBTQ populations. While the full impact of this form of invisibility
or erasure on the health of LGBTQ populations in Nova
Scotia is not well understood, a previous study on the
experiences of queer and trans women in Nova Scotia
found that participants experienced significant discomfort in their interactions with healthcare providers and
expressed fear that they would be denied adequate
health care based on their sexual orientation or gender
identities [10].
The way in which health and wellness are defined has
important implications for how research evidence is
understood and reported. The Public Health Agency of
Canada (PHAC) borrows its definition of health from
the World Health Organization (WHO), which has long
defined health as “a state of complete physical, social
and mental well-being, and not merely the absence of
disease or infirmity” [11]. The PHAC also recognizes
that the health of individuals and populations is
influenced by a variety of intersecting and overlapping
determinants at both the individual and structural levels,
including income and social status, social support
networks, education and literacy, employment/working
conditions, social environments, physical environments,
personal health practices and coping skills, healthy child
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development, biology and genetic endowment, health
services, gender, and culture [12]. Despite this recognition, public health policy and practice in Canada have
traditionally focused on individual health and on interventions that target individual behaviour [6, 13]. The
emphasis on individual-level health outcomes further
obscures the ways in which structural determinants of
health such as heteronormative health care systems and
policies in Canada can negatively impact on health care
access and uptake among LGBTQ populations [6].
Although PHAC does not recognize LGBTQ identity as a key social determinant of health [12], it is
important to consider how sexual orientation and
gender identity intersect with other determinants to
shape the health of LGBTQ individuals. The concept
of intersectionality is key to understanding health outcomes among LGBTQ populations in that health is
determined by the complex interactions of LGBTQ
identity with other factors such as race, socioeconomic status, age, social exclusion, employment, etc.
[14, 15]. For example, previous research has demonstrated that LGBTQ populations experience higher
rates of homelessness, social exclusion, poverty, and
other negative determinants of health compared to their
heterosexual, cisgender, age-matched peers [16–19]. Bowleg, Huang, Brooks, Black, and Burkholder contend, for
example, that the health of black lesbians is affected by
the ‘triple threat’ of racism, sexism, and heterosexism [20].
Further, social stigma, discrimination, and victimization
have been found to not only have negative effects on
physical and mental health [21], but also to affect rates of
access to and uptake of preventative health screening
programs and health care services among LGBTQ populations [6, 22–24]. According to the findings of an earlier
study on lesbian and bisexual women’s experiences with
family physicians in Nova Scotia, more than two-thirds of
the 98 women interviewed reported encountering heterosexist assumptions and many women reported avoiding
routine or preventative health care due to health care providers’ heteronormative assumptions [25]. As such, the
overemphasis on individual-level health factors contributes to the invisibility or erasure of the health needs and
experiences of LGBTQ populations by obscuring the
unique social, structural, and systemic determinants that
impact the health outcomes of these populations [26, 27].
The lack of health data on, and the resultant invisibility of, LGBTQ health needs and experiences in
Nova Scotia highlights the importance of conducting
research focused specifically on these topics. The
long history of health research approaches that have
tended to psychopathologize differences between
LGBTQ populations and heterosexual and cisgender
populations [6, 28, 29] has reinforced the framing of
LGBTQ health as the inability to maintain health at
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the level of the individual. Based on this framing of
LGBTQ health, much health research has tended to
focus on risks for poor health outcomes among
LGBTQ populations, particularly rates of STI and
HIV infection, smoking, obesity, depression, and
suicidal ideation [30–32]. Although early health
research played an important role in identifying,
mitigating, and treating poor health outcomes among
LGBTQ populations as something more than an
individual deficit, it also served to create negative
perceptions of LGBTQ health and obscured the ways
in which these populations maintain their health. As
such, it is necessary to shift away from deficitfocused heath research toward strengths-based
perspectives that take a more holistic approach to
understanding LGBTQ health across the life course
[33–36]. Strengths-based perspectives do not ignore
health risks and challenges but rather focus on the
positive resources available to address these risks
and challenges [37]. Improving cultural competence
within health care systems, policies, and services in
Nova Scotia requires acknowledging, rendering
visible, and appropriately measuring the determinants of LGBTQ health and wellness across the life
course [38, 39].
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The purpose of this paper is to offer an overview of the
findings of a scoping review and community consultations aimed at developing strengths-based approaches to
understanding LGBTQ pathways to health in Nova
Scotia. The scoping review and community consultations
are nested within a larger program of research aimed at
rendering visible the health needs, outcomes, and lived
experiences of LGBTQ populations in Nova Scotia in an
effort to improve access to, and the provision of,
evidence-based, culturally competent health care for
these populations.
Methods
The research described in this paper is informed by the
central tenets of community-based participatory
research. Community-based participatory research
involves “individuals and communities affected by the
research in all aspects of the research process, reciprocal
learning from the expertise of the members, shared
decision-making, and mutual ownership of the processes
and products of the research” (Van Wagenen et al., [40],
p. 4). In this regard, we sought to include LGBTQ populations and other stakeholders, such as health care
providers, health researchers, and policy makers, in
every stage of this research.
In an effort to gain a clearer understanding of the
existing health-focused LGBTQ literature, we conducted
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a scoping review using the methodology proposed by
Arksey and O’Malley [41]. The purpose of our scoping
review was to explore the academic, peer-reviewed
health research literature specifically for strengths-based
approaches to understanding LGBTQ health. In accordance with community-based participatory research
methodology, we consulted with a community advisory
committee comprised of LGBTQ community members,
representatives from LGBTQ organizations, LGBTQ
health researchers, and a health reference librarian to
determine the search terms for our scoping review (see
Appendix 1). We then conducted a search of five key
databases containing academic, peer-reviewed journals
using these search terms. Our initial search yielded a
total of 1855 de-duplicated results, of which 105 articles
met the inclusion criteria. Given that the health sector
tends to draw on peer-reviewed evidence to inform best
practice for clinical care and related health practice
guidelines, only articles published in peer-reviewed
academic journals that discussed research from
strengths-based or health promotion perspectives were
eligible for inclusion (see Appendix 2). As such, studies
that relied primarily on a health deficit model or risk
assessment approach to studying LGBTQ health were
excluded. We also included studies that presented
alternative analytical and methodological frameworks
such as needs assessments, which can help challenge
heteronormative and cisnormative approaches to
LGBTQ health by allowing LGBTQ populations to identify their own health needs. To ensure that the included
studies are relevant to the context of Nova Scotia and to
the Canadian health care system, only studies published
in English and conducted in Canada, the United States,
the United Kingdom, Australia, or New Zealand were
considered for inclusion. The scoping review was conducted in October 2014 and only papers published by
that time were considered. We did not, however, limit
our findings to a particular start date. To ensure rigour,
an inter-rater reliability approach was used in the inclusion process whereby both the research assistant and
principal investigator reviewed all articles flagged for
possible inclusion. Articles selected for inclusion were
read and thematically mapped by research question and
methodological approach for consideration for health
research and promoting LGBTQ health and wellness in
the context of Nova Scotia.
Given the importance of engaging with LGBTQ
populations, community consultations were undertaken
following the completion of our scoping review to
discuss the findings and their relevance in the context of
Nova Scotia. We conducted two community consultations with LGBTQ populations and health service
providers in Truro and in Halifax. Participants were recruited through word of mouth and through existing
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community networks in both urban and rural Nova Scotia. In total, there were twenty participants, six of whom
attended the rural consultation in Truro and fourteen of
whom attended the urban consultation in Halifax. Participants ranged in age from mid-20s to late 60s and the
majority identified as white. Prior to data collection, ethics approval was provided by the Dalhousie University
research ethics board (REB #2014-3291) and informed
consent was obtained from all participants. All data were
audio recorded with permission, transcribed verbatim,
and analyzed for key emergent themes. In addition to
sharing the findings of the scoping review, the overarching purpose of these consultations was to discuss strategies for conducting strengths-based research on
LGBTQ health needs, outcomes, and experiences in
Nova Scotia. The community consultation transcripts
were analyzed and coded for emergent themes.
283 Results
284 Scoping review findings
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Overall, the findings of our scoping review confirmed
that the majority of LGBTQ health research conducted
to date has largely remained focused on risks and deficits, underscoring the need to shift towards strengthsbased approaches. It is also noteworthy that very few of
the studies that met our inclusion criteria were conducted in Canada (n = 16) or were conducted in multiple
countries but included populations in Canada (n = 3)
(see Appendix 3) and only one study specifically included LGBTQ populations in Nova Scotia. This finding
further illustrates the need for strengths-based research
focused on the health needs and experiences of LGBTQ
populations in Nova Scotia. The included studies also
featured a range of study populations and terminology
(see Appendix 4). While some studies focused on
LGBTQ populations in general, others focused on specific subpopulations. Notable subpopulations included
youth (n = 26), older adults (n = 14), and people of
colour (n = 14). Although we did not limit our studies to
a particular start date, the findings demonstrate that
strengths-based research on LGBTQ health is becoming
increasingly prevalent. Of the included studies, none
were published prior to 1990, six were published between 1990 and 1999, 36 were published between 2000
and 2009, and 68 were published between 2010 and
2014 (See Appendix 5).
The articles included in our scoping review explored a
wide range of protective or health promoting factors
with the potential to contribute to LGBTQ health, including, for example, social support, coping skills, and
positive school and/or work environments [33, 42–44].
Further, these studies used diverse tools to measure
positive health factors. However, we also noted that
many of the measures used were not specific to LGBTQ
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populations, and, as such, their appropriateness and utility as tools to measure LGBTQ health in Nova Scotia
may be limited. Although the included studies employed
a wide variety of different qualitative, quantitative, and
mixed methods approaches, the use of online surveys
was relatively common (n = 28). This finding is significant in that online surveys may provide participants with
a greater degree of anonymity and have therefore been
identified as an effective and appropriate way of reaching
‘hidden populations’, including LGBTQ populations, for
research [29, 45–50]. The use of focus groups and interviews was also common and may be an important means
of allowing LGBTQ populations to identify and discuss
their own health needs and experiences.
Many of the studies included in the scoping review
also featured an element of community involvement.
While some involved a community advisory committee
[51–54], others conducted their research in partnership
with community-based organizations or service providers with the goal of informing the development or
improvement of programs and services for LGBTQ populations [55–59]. These approaches are in keeping with
the principles of community-based participatory
research [40].
The concept of resilience, referring to the ability to
overcome or positively adapt in the face of significant
adversity, emerged as a commonly cited framework or
theme but there is debate about whether this concept
is inclusive of LGBTQ lived experiences [36, 43, 44].
While many of the included studies suggested that
LGBTQ populations are in fact resilient [20, 34, 43,
60–63], resilience was not consistently defined or
measured across these studies. In addition, there was
no clear consensus on the factors that contribute to
resilience among LGBTQ populations. Like health
care systems and policies, resilience has historically
been focused on individual level determinants of
health, which has led some to characterize resilience
as a set of inherent personal traits or skills [64–66].
This is particularly concerning given the ways in
which the overemphasis on individual-level factors
associated with health has contributed to the invisibility of LGBTQ health needs, outcomes, and
experiences. As with the remainder of the measures
used in the studies included in our scoping review,
the majority of tools used to measure resilience were
not LGBTQ-specific. There is also a need to approach
resilience from an intersectional lens as it has
historically been defined and framed from a Western
perspective [65]. Overall, there is some uncertainty
regarding the appropriateness and utility of the
concept of resilience for LGBTQ health research in
Nova Scotia and this knowledge gap warrants further
exploration.
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Colpitts and Gahagan BMC Public Health (2016) 16:1005
373 Community consultations
374 The following section offers
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an overview of the key concerns raised about LGBTQ health in Nova Scotia from
our community consultations. Our semi-structured
focus group guide centred around core issues to emerge
from our scoping review, including experiences with
health care systems and services, factors seen to contribute to LGBTQ health and wellness, LGBTQ resilience,
improving the cultural competence of health care systems and services, and finally, suggestions for future
LGBTQ health research in Nova Scotia.
384 Negative experiences with health care systems and services
385 Following the scoping review, the community consult386
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ation discussions offered a rich overview of LGBTQ experiences with health care systems and services, factors
that contribute to LGBTQ health and wellness, and how
LGBTQ pathways to health in Nova Scotia can be improved. Unsurprisingly, many of the LGBTQ participants
attending the consultations reported negative experiences with health care services in Nova Scotia. Several
participants described having negative first impressions
of health care settings based on their interactions with
medical office assistants and heteronormative, genderbinary language on medical intake forms. In other
words, intake forms and salutations required patients to
select gender-congruent ‘male’ or ‘female’ categories and
to select corresponding terms such as ‘Mr.’ and ‘Mrs’. As
one participant explained, “I shouldn’t have to go into a
doctor’s office and be like I’m probably going to get misgendered and I need to prepare myself for that and put
on my armour. That shouldn’t even be happening in the
first place. But it does happen and it’s my reality, and I
have to deal with it”. Similarly, participants expressed
concern about the challenges of communicating with
health service providers and being open with them regarding their LGBTQ identity—both in terms of sexual
orientation and gender identity. One participant characterized this experience as “explaining yourself over and
over” when interacting with health service providers.
Participants suggested that these negative encounters
serve to discourage LGBTQ populations from accessing
regular check-ups and preventative care, and instead,
waiting until they are ill before seeking health care services. Participants also expressed concern regarding
health service providers’ lack of knowledge on LGBTQ
health issues, which may lead to inappropriate advice.
One participant shared the story of a friend in a rural
setting whose doctor threatened to involuntarily commit
them for psychiatric care based on their non-binary gender identification. This experience is supported by the
findings of a previous study on lesbian and bisexual
women in Nova Scotia wherein several women reported
being told by a physician that their sexuality was
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pathological and referred to psychiatric services [25].
Another participant felt that health care providers in
Nova Scotia may have lower expectations for their
health outcomes and that this may lead to a lower standard of care in comparison with other provinces. These
experiences were summarized by a participant who
stated “I feel like I am surviving the health care system”.
Thus, while the focus of the consultations was on advancing strengths-based research on LGBTQ pathways to
health, it is important to acknowledge these negative experiences as they reinforce the importance of understanding and reconciling these tensions in access to and
uptake of health care services and programs.
Factors contributing to LGBTQ health and wellness in Nova
Scotia
One of the central discussion questions during the community consultations focused on the factors that are
regarded as keeping LGBTQ populations in Nova Scotia
well and promoting their health across the life course.
Participants reflected on many different factors, ranging
from the individual level to broader social and structural
levels. Although some of these factors may also be determinants of health for the broader population, others are
specific to LGBTQ populations. Participants listed
widely recognized social determinants of health including socioeconomic status, access to housing, education,
social isolation, and food security as key to promoting
health. While these factors may be considered determinants of health for all populations, it is important to
recognize how these factors intersect with LGBTQ identities. For example, as previously mentioned, LGBTQ
populations face higher rates of homelessness and
poverty than their heterosexual, cisgender age-matched
peers [16–18]. These factors are also interconnected; as
one participant pointed out, poverty among older
LGBTQ populations may, for example, prevent individuals from engaging in social activities, thereby contributing to social isolation.
Participants identified health literacy and knowledge of
one’s own health issues as important individual-level
factors. Participants suggested that the ability to read
and process health information has a significant impact
on individuals’ awareness of their own health and
wellness. While the issue of health literacy may not be
unique to LGBTQ populations, they experience particular challenges in accessing appropriate and meaningful
health information that speaks to their LGBTQ identities
and lived experiences. Participants argued, for example,
that sex education currently tends to be framed through
a heteronormative and gender-binary lens, thereby limiting its utility for LGBTQ youth. Self-acceptance and
levels or degrees of ‘outness’ to health service providers
were also described as important health promoting
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factors. As one participant noted, “it took me a long
time to get to that point to be able to talk openly about
my own body [and] my own sex life”. Most participants
reasoned that while not being ‘out’ to a health service
provider can potentially have negative implications for
health, it is also a necessary part of the process of accessing health care in order to negotiate personal safety in
instances where there is uncertainty or lack of trust with
a health care provider. Similarly, not being ‘out’ was seen
as a factor preventing LGBTQ populations from accessing certain community organizations and services for
fear of being identified as LGBTQ. In addition, cognitive,
behavioural, and emotional personal coping strategies
and self-care were viewed as key individual-level factors
contributing to the health and wellness of LGBTQ populations in Nova Scotia.
As one participant cautioned, it is imperative that
individual-level factors are not overemphasized:
when we take the emphasis off the system and put it
on the individual, I worry a little bit about victim
blaming…[if] I go to get care, there’s a 50 per cent
chance that I’m going to leave worse than when I
went in and that’s not my fault…We should also
recognize that in acquiring those [personal coping]
tools that there’s an injustice happening.
Consistent with our scoping review findings, social
support was one of the most prominent determinants
seen as contributing to LGBTQ health and wellness. Potential sources of social support include biological family
or family of origin, family of choice, friends, and other
LGBTQ community members. Community connectedness was also seen as a source of strength among participants. Participants defined community connectedness
quite broadly, referencing involvement in gay-straight
alliances, LGBTQ communities, sports leagues, community activities such as Pride Week, and accessing
community services as potential connections. Similarly,
participants suggested that for LGBTQ populations for
whom religion or spirituality are important, belonging to
an affirming religious or spiritual community could play
a critical role in maintaining health and wellness. As one
participant explained,
a lot of people who are [LGBTQ]… don’t feel
right in the eyes of God. So they really kind of
have to feel connected to a faith to actually feel
that they are okay. And so we have a church that’s
all affirming and we have a gay couple, one is the
minister, and the whole church is just so
supportive. They have rainbow stickers
everywhere. So it’s that opportunity to start to feel
a little bit more healthy within yourself, a little bit
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more whole within yourself, if that’s what you
want to do.
Participants viewed the issue of pride in LGBTQ
history as another important factor contributing to the
health and wellness of LGBTQ populations in Nova
Scotia. One participant shared stories of LGBTQ individuals who faced significant adversity but overcame
them, demonstrating their strength and resilience. The
participant argued that “we need more pride in our
history. We need more pride in our people… and not
just the ones that stood in front of the camera and
became movie stars; the people that lived ordinary lives
in rural communities, that lived, loved, and maybe died.
But they lived together”. The same participant argued
that sharing these stories and histories can be an important source of strength for LGBTQ populations. Similarly,
participants suggested that having positive LGBTQ role
models is a key factor contributing to their sense of
wellness and social connectedness. Other factors
included having safe and supportive work and/or school
environments. In this regard, participants argued that
acceptance within the community and in other environments is an important contributor to health. For
example, one participant suggested that an individual’s
social status within the community (in terms of recognition and respect) might impact acceptance within the
community, which, in turn, might affect the likelihood
that the individual will feel comfortable seeking health
care services.
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LGBTQ resilience
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We also asked participants in the community consultations whether they felt that the concept of resilience was
relevant to understanding the health needs, outcomes,
and experiences of LGBTQ populations in Nova Scotia.
Consistent with the lack of clarity on this concept in our
scoping review results, participants spoke of the need for
clarification on how resilience is defined. While participants generally felt that LGBTQ populations in Nova
Scotia are resilient, the utility of this concept for LGBTQ
health research remained unclear as participants struggled to define it, identify the factors that comprise it,
and determine how it should be measured. This led one
participant to suggest that future research should ask
LGBTQ populations how they perceive their own resilience and how they would compare it to the resilience of
others. Participants also discussed the need to consider
measuring whether and how resilience changes over
time, depending on the complex interactions of
determinants of health. In terms of the determinants
contributing to resilience among LGBTQ populations,
participants repeated many of the same modifiable and
non-modifiable determinants discussed above, including
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social support, pride, self-acceptance, community connectedness, and personal coping skills.
584 Improving the cultural competence of health care systems
585 and services in Nova Scotia
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In addition to determinants that contribute to promoting the health and wellness of LGBTQ populations in
Nova Scotia, participants also discussed ways in which
the cultural competence of health care systems and services in Nova Scotia could be improved. One of the key
areas of improvement noted was making health care environments safer and more inclusive and welcoming for
LGBTQ populations. Participants argued that making
small changes within health and social systems such as
removing heteronormative and gender-binary language
from intake forms and posting visible symbols like a
pride flag or an LGBTQ ally card would contribute to
improving pathways to health for LGBTQ populations.
As one participant explained:
if you change spaces then you could change who
accesses the spaces…If I walk into a space where I see
a poster on the wall where my identity is reflected,
and I see a tick box on a form and know that that
healthcare provider expects me in the room, then I’m
more likely to access those services again.
Additionally, education and training for health care
providers on how to provide culturally competent health
care services for LGBTQ populations was seen as a
major area for improvement. A nurse attending one of
the consultations stated that, in her experience, nurses
are not taught “how to make an equitable presentation
for an experience in health care whatsoever. It’s just not
there. We might be given one session one afternoon in
our undergrad, and that’s it. And this was 2 years ago
when I graduated”. This feeling echoes the views of
physicians interviewed in a previous study on queer and
trans women’s health care in Nova Scotia who felt that
they lacked knowledge, particularly with regards to
providing care for trans populations [10]. Another
participant felt that the only way to ensure positive experiences of ‘coming out’ to health service providers is
through additional education and training. This finding
is supported by the conclusions of a previous study that
found that nurses in Nova Scotia “take a ‘don’t ask, don’t
tell’ approach, trusting that quality care can be provided
without acknowledging LGBTQ identities and that the
ways in which marginalization and oppression may
shape LGBTQ patients’ health and health care” (Beagan
et al. p.60 [67]). Beyond improving communication
between health service providers and LGBTQ
populations, educating health service providers on
LGBTQ-specific health needs and issues was also seen
Page 7 of 12
as critically important. Overall, participants felt that
education related to culturally competent care is
essential for all individuals working in health care
services, including medical office administrators, who
are often the first people that patients interact with. One
participant suggested that efforts could be made to
increase the number of LGBTQ individuals interested in
undertaking training to become health care providers in
Nova Scotia and to offer them support for their training.
Participants argued that advocacy plays a significant
role in improving pathways to health for LGBTQ populations in Nova Scotia. One participant stated that
knowing their rights as a patient, such as the right to
bring a friend along to an appointment, to record
appointments, and to pursue formal resolution if something goes wrong, would have made them less likely to
experience discrimination. Further, participants argued
that having LGBTQ patient advocates who could assist
LGBTQ populations in navigating health care systems is
an important means of improving LGBTQ pathways to
health in Nova Scotia.
Participants also shared their views on the norms that
should be central in health care services and systems in
Nova Scotia. For example, one participant argued that
“continuity of care, meaning that you have access to a
healthcare provider that you know and [that] care is personalized” is critical. Participants discussed the notion of
informed consent in health care and the importance of
making sure that patients have all of the necessary information to make informed decisions regarding their own
health and wellness. Finally, participants viewed the notion that patients’ decisions will be supported by their
health service providers as being critical in improving
health care services and systems for LGBTQ populations
in Nova Scotia.
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Suggestions for future LGBTQ health research in Nova
Scotia
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Participants in the community consultations also identified a number of key questions for future strengthsbased, health promotion research on understanding
LGBTQ health in Nova Scotia. Several research questions centred on health care experiences and access.
These questions included “have you ever had a positive
[or inclusive] interaction with a health care provider?”,
“what did that look like?”, and “how did that make a difference?”. Other participants noted that having access to
a doctor in Nova Scotia can be a challenge and as such,
it is important to ask whether LGBTQ populations have
access to a doctor and whether they have a choice of
doctors. Participants suggested that LGBTQ populations
might seek health care services from providers other
than their doctor, such as community nurses and teen
health nurses, and that research should explore which
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health care provider they choose to see first and why.
Participants also felt that it is important to ask LGBTQ
populations whether they feel that their health service
providers are LGBTQ-friendly and knowledgeable of
LGBTQ health issues.
Based on the factors discussed above, participants
suggested a number of key issues related to how LGBTQ
populations in Nova Scotia maintain and improve their
own health and wellness across the life course. For example, participants felt that it was important to ask
whether LGBTQ populations are ‘out’ at work and/or
school, whether these are positive environments, and if
so, what factors contribute to making these environments positive. With respect to personal coping skills,
participants argued that it is imperative to ascertain not
only whether an individual possesses coping skills, but
also how effective they are, how diverse their coping
toolkit is, and whether they have the ability to develop
new coping skills. Participants suggested that it is important to determine the number of support people that
an LGBTQ individual has, as well as the role that those
people play, and how social support affects their health
and wellness.
When asked to identify who should be included in future health research focused on LGBTQ health, in
addition to LGBTQ populations, participants suggested
a wide range of health service providers, including emergency departments, medical office administrators,
nurses, physical therapists, occupational therapists, teen
health nurses, long-term care providers, telemedicine
providers, public health policy makers, midwives, and
continuing care assistants. In keeping with the emphasis
on improving culturally competent responses among
health service providers, participants felt that it was also
important to include those responsible for educating
health service providers, as well as students training to
become health service providers. Finally, participants
suggested including non-profit organizations that provide services for LGBTQ populations, such as shelters.
Discussion: advancing LGBTQ health research in
Nova Scotia
Based on the findings of our scoping review and community consultations, we argue that the determinants of
LGBTQ health must be understood through a model
that considers both individual and structural factors. For
example, a lens of intersectionality acknowledges that
health outcomes among LGBTQ populations are a result
of the intersections of their LGBTQ identities with other
determinants of health, including race, socioeconomic
status, social exclusion, employment, etc. (see [65] for
example). Further, the relationship between these factors
and health outcomes is complex. For instance, while alcohol use may potentially contribute to negative health
Page 8 of 12
outcomes, it may also mitigate social isolation by allowing individuals to overcome social anxiety. Perhaps most
importantly, rather than focusing on individual-level factors such as individual behaviour, it is important to consider how structural factors shape and influence
individual risks for negative health outcomes. Similarly,
rather than focusing on developing personal coping
skills, there is a need to address social and structural factors such as homophobic and transphobic stigma and
discrimination, particularly within health care systems,
that may necessitate the use of personal coping skills.
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Implications for LGBTQ health research
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Efforts to better understand the complex pathways to
health among LGBTQ populations in Nova Scotia
should include collecting additional data on the health
needs, outcomes, and lived experiences of LGBTQ populations in Nova Scotia. The purpose of our scoping review and the community consultations described in this
paper was to help inform future LGBTQ health research
by exploring knowledge gaps in relation to how to
understand LGBTQ health in Nova Scotia from a
strengths-based perspective. Although capturing data on
negative health outcomes and experiences of LGBTQ
populations plays an important role in identifying, mitigating, and treating health issues, future health promotion research on LGBTQ health in Nova Scotia should
also capture the ways in which LGBTQ populations
maintain and improve their own health and wellness
across the life course.
The strengths-based studies in our scoping review and
the community consultations data provide important insights into the factors that potentially promote the
health of LGBTQ populations in Nova Scotia. These
strength-based determinants range from the individual
level to the structural and social levels. In particular, the
importance of personal coping skills, social support networks, and community connectedness were frequently
cited in the scoping review and consultations as important determinants of LGBTQ health. Future health promotion research on LGBTQ populations in Nova Scotia
should investigate the presence and significance of these
factors and the potential for health promotion interventions to build on these strengths. At the structural level,
supportive work and school environments, accepting
communities, and safe, inclusive, and welcoming health
care spaces were considered to have a major impact on
LGBTQ pathways to health. Additional research on
these structural factors in the context of Nova Scotia
could contribute to policy changes that could have positive impacts on LGBTQ health outcomes. The utility of
resilience as a strengths-based conceptual framework for
understanding and measuring LGBTQ health in Nova
Scotia also warrants further exploration. Finally, given
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Colpitts and Gahagan BMC Public Health (2016) 16:1005
that we were only able to conduct community consultations in two regions, there is a need for additional
794 research on LGBTQ health in Nova Scotia that captures
795 the perspectives of LGBTQ populations across the
796 province.
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797 Limitations
798 Although our
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scoping review and the community consultations provide important information for conducting
strengths-based LGBTQ health research, there are several limitations to note. The scoping review only included peer-reviewed, academic articles published in
English and in academic journals and, as such, may not
reflect the perspectives of non-peer reviewed or grey literature. Further, given the diversity of identities and
terms related to LGBTQ populations (see Appendix 4),
there may be identities or populations that were not adequately captured by the search terms, such as men who
have sex with men (MSM) but do not identify as gay or
bisexual, for example. While scoping reviews are a useful
approach to retrieving literature related to a specific
topic of interest and identifying gaps in the existing literature, they do not assess the quality of the evidence or
synthesize the findings presented in the retrieved literature in the way that systematic reviews do [41]. As such,
future research on this topic should consider including
systematic reviews which provide a more rigorous methodology. In addition, the community consultations were
limited by time and budgetary constraints which only
allowed for two consultations, one in rural and one in
urban Nova Scotia. Moreover, although we sought to
make the consultations safe, inclusive, and respectful
spaces, we invited both LGBTQ populations and health
service providers to attend. This may have deterred
LGBTQ individuals who have had negative health care
experiences from attending. While we have highlighted
the importance of intersectionality in LGBTQ health research, the majority of our community consultation participants identified as white and, as such, do not
necessarily represent the diversity of LGBTQ populations in Nova Scotia. Future research should consider
using alternative recruitment strategies that may result
in greater diversity among participants.
Conclusion
As the findings from our scoping review and community consultations demonstrate, there is an urgent
need to conduct health research on the unique health
needs, lived experiences, and outcomes of LGBTQ
populations in Nova Scotia to ensure that current
health policies, programs and services are responsive
to these populations. Given the historical emphasis on
negative health outcomes among LGBTQ populations,
it is important that future health research be
Page 9 of 12
conducted from an intersectional, strength-based perspective in an effort to highlight not only the health
risks and challenges experienced by LGBTQ populations, but also positive approaches to addressing these
issues. Specifically, additional health promotion research that takes into account the social, systemic,
and structural determinants of LGBTQ health is
warranted.
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Appendix 1
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Table 1 Search terms used in scoping review
Concept 1:
LGBTQ identity
Concept 2: health
Two spirit
Resilienc*
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851
t1:1
Concept 3:
t1:2
measurement t1:3
Data collection t1:4
Lgb*
Protective factor*
Survey*
t1:5
Gender minorit*
Health promot*
Model*
t1:6
Sexual minorit*
Health protect*
Framework*
t1:7
Trans sexual*
Life course*
Measure*
t1:8
Trans gender*
Harm reduction
Tool*
t1:9
Gender identit*
Health predict*
Assess*
t1:10
Gender varian*
Social determinants of health
Epidemiology
t1:11
Genderqueer*
Health disparities
Module
t1:12
Queer*
Health status
Evaluat*
t1:13
Gay*
t1:14
Lesbian*
t1:15
Bisexual*
t1:16
Transgender*
t1:17
Transsexual*
t1:18
Homosexual*
t1:19
Intersex*
t1:20
Appendix 2
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Table 2 Inclusion/Exclusion criteria for scoping review
t2:1
t2:2
t2:3
Inclusion
Exclusion
Published in English
Published in language other
than English
Peer-reviewed
Non peer-reviewed
t2:4
Academic journal article
Book, dissertation, conference
abstract, etc.
t2:5
Primary study
Not a primary study
t2:6
Study conducted in US, UK, Australia,
New Zealand or Canada
Study conducted in country
other than US, UK, Australia,
New Zealand or Canada
t2:7
t2:8
Approaches LGBTQ health from a
strengths-based or health promotion
perspective
Approaches LGBTQ health from t2:9
a deficit-based or risk-focused
t2:10
perspective
t2:11
Time Frame: The scoping review was conducted in October 2014. All included
results were published before then. We did not limit our search using a
start year
t2:12
t2:13
t2:14
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856
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Appendix 3
t3:1
t3:2
t3:3
Country
# of studies
United States
70
t3:4
United Kingdom
3
t3:5
Canada
16
t3:6
New Zealand
5
t3:7
Australia
6
t3:8
Multiple countries
5
Appendix 4
t4:1
t4:2
Study population
# of
studies
t4:3
Gay men
16
t4:4
t4:5
Gay and bisexual men or men who have sex with men
(MSM)
12
t4:6
Bisexual individuals
2
t4:7
Lesbian women
10
t4:8
Lesbian and bisexual women
2
t4:9
Table 4 Study populations
Transgender individuals
16
t4:10 Gay and lesbian individuals
4
t4:11 Lesbian, gay, and bisexual individuals (LGB)
9
t4:12 Lesbian, gay, bisexual, and transgender individuals (LGBT)
15
t4:13 Lesbian, gay, bisexual, transgender, and queer individuals
t4:14 (LGBTQ)
7
t4:15 Sexual minority individuals
5
t4:16 Transgender, queer, and questioning individuals (TQQ)
1
t4:17 Gay, lesbian, bisexual, transgender, and intersex individuals
t4:18 (GLBTI)
2
t4:19 Gay and bisexual men and male-to-female (MTF) transgender 1
t4:20 individuals
t4:21 Lesbian, gay, bisexual, and queer individuals
2
t4:22 LGBTQ women
1
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861
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866
Acknowledgements
We wish to thank PrideHealth and the (former) Capital District Health
Authority for providing funding for this research. We also wish to thank
Cybelle Rieber for her review of the earlier version of this manuscript.
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Funding
PrideHealth and the (former) Capital District Health Authority provided
funding for the scoping review and community consultations. They also
provided funding for EC to draft this manuscript.
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Availability of data and materials
The datasets generated during and/or analysed during the current study
available from the corresponding author on reasonable request.
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Authors’ contributions
EC participated in the study design, participated in conducting the scoping
review, analyzed the scoping review data, co-facilitated the community
consultations, analyzed the consultations data, and drafted and revised the
manuscript. JG conceived the study, participated in the study design and
conducting the scoping review, co-facilitated the community consultations,
and revised the manuscript. Both authors read and approved the final
manuscript.
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Competing interests
The authors declare that they have no competing interests.
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Consent for publication
Not applicable.
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Ethics approval and consent to participate
Prior to data collection, this study received ethics approval from the
Dalhousie University Research Ethics Board (REB #2014-3291). Informed
consent to collect, record and report the data was obtained from all
community consultations participants.
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Received: 22 July 2015 Accepted: 16 September 2016
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