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Journal of Primary Health Care Journal of Primary Health Care Society
Journal of The Royal New Zealand College of General Practitioners
RESEARCH ARTICLE (Open Access)

Rainbow health in Aotearoa New Zealand – finally getting the attention it deserves?

Jeffery Adams https://orcid.org/0000-0003-3052-5249 1 * , Stephen Neville https://orcid.org/0000-0002-1699-6143 2
+ Author Affiliations
- Author Affiliations

1 SHORE & Whāriki Research Centre, Massey University, PO Box 6137, Auckland 1141, New Zealand.

2 Te Pūkenga, PO Box 19400, Hamilton 3244, New Zealand.

* Correspondence to: j.b.adams@massey.ac.nz

Journal of Primary Health Care 15(2) 186-189 https://doi.org/10.1071/HC22152
Published: 21 February 2023

© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of The Royal New Zealand College of General Practitioners. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)

Introduction

The health of Rainbow people (an umbrella term for people who are transgender or gender diverse, not straight/heterosexual, and who are intersex),1 has until now largely been ignored in government health policy.2 This has changed with the release by Te Whatu Ora and Te Aka Whai Ora of Te Pae Tata: Interim New Zealand Health Plan,3 which details priority areas to improve health outcomes and equity for all New Zealanders. Rainbow people are specifically mentioned in Te Pae Tata as a key population (Table 1).


Table 1.  Te Pae Tata: Interim New Zealand Health Plan.
T1

Although this commitment to enhancing Rainbow people’s health and primary health care is welcomed, in this Viewpoint, we offer further considerations for ensuring Te Pae Tata delivers on its intentions.


Acknowledging health inequity is significant

Government acknowledgement of health inequity for Rainbow people is a significant milestone. Previous recognition of Rainbow health inequity has focused on youth mental health4 and HIV prevention.5 Although these are unequivocally important health issues, compelling international evidence demonstrates inequity for Rainbow people occurs across a wider range of health issues.6

When compared with the robust international evidence, the health status and healthcare experiences of Rainbow people in New Zealand remain largely unknown. For example, although relevant data about health status, health behaviours and risk factors, utilisation of and experiences of health services of sexual minority people (lesbian, gay, bisexual) have been collected in the NZ Health Survey since 2015, these data have not been comprehensively analysed for Rainbow people. One relevant study using these data reports sexual minority people engage in more hazardous alcohol drinking than non-sexual minority people.7

The burden of documenting Rainbow people’s health has fallen on community-led research. One strong theme in that research is that many Rainbow people, including Takatāpui (Rainbow-identifying Māori),8 avoid or delay engaging with healthcare services, and when they do engage, experience poor quality and inappropriately delivered primary health and other health services.1,912 For Takatāpui, negative experiences of health care are underpinned by discriminatory beliefs, assumptions or practices, in terms of both racism and homophobia.9

Making fuller use of existing data and ensuring future data collection meaningfully includes Rainbow people would strengthen the evidence base and provide a fuller understanding of health disparities and better inform future healthcare policy and service planning and delivery. In line with this, it is pleasing that the 2023 Census onwards will include demographic questions about gender, sexual identity, and variations of sex characteristics,13 and that the NZ Household Economic Survey14 already collects relevant information.


A welcome focus on health services – but determinants of health are wider than this

Te Pae Tata has identified improving the access and quality of primary health and other health services for Rainbow people (especially for transgender and intersex) as a priority. This focus makes sense as both Te Whatu Ora and Te Aka Whai Ora are responsible for leadership in ‘shaping’ the future healthcare system.

Missing in Te Pae Tata, however, is reference to the non-medical factors that influence the health of Rainbow people. These social determinants are the ‘conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life’.15 For example, transgender people in New Zealand earn less,16 Takatāpui are more likely to homeless,17 young Rainbow people experience bullying at school18 and South Asian Rainbow people report significant experiences of discrimination.19 Such factors impact on Rainbow peoples’ physical and mental outcomes, health practices and behaviour. In relation to alcohol use, for example, Rainbow people have justified problematic drinking of alcohol as a way of coping with exclusion, stigma and distress.20


A diverse Rainbow community must be accounted for

Te Pae Tata uses the phrase ‘Rainbow community’. This notion of a singular community recognises commonalities in experiences of discrimination and ‘otherness’;21 however, an unintentional effect of this is hiding differences between groups (eg between cisgender gay men and transgender men) and within groups (eg younger lesbians and older lesbians).

Examples of diverse health-related knowledge and behaviours are evident among Rainbow people. As noted earlier, for example, hazardous drinking has been identified among sexual minority people. However, a detailed analysis shows differences in drinking between sexual minority and non-sexual minority people are largely driven by sexual minority women.7 Other research has demonstrated that even within a more defined group – Asian gay and bisexual men – sexual health knowledge varies between those born in New Zealand and those born overseas, as well as between Chinese, South Asian and Filipino men.2224

Health inequity for Rainbow people is often impacted by other identities they hold – such as age (including younger and older),18,2529 ethnicity,9,19,30,31 migrant status,22,23 disability,32 or involvement with social care agencies.33 Understanding how these identities intersect and how they are negotiated and managed by individuals is necessary, as this may contribute to additional social marginalisation and negatively influence health outcomes.


Increasing Rainbow competency of primary health and other health services

Central to Te Pae Tata is ensuring Rainbow community members have access to services that work for them; this is vital, as many primary health care and other health services are not currently working well for many Rainbow people. Given the crucial role of primary health care in health service delivery, the commitment within the plan to work closely with providers to grow the breadth and depth of services is relevant. At a minimum, all health services must be culturally safe and welcoming. Healthcare environments and providers must foster confidence among Rainbow people that respectful practitioner–patient relationships can be developed.34

All staff must be competent regarding Rainbow healthcare needs and demonstrate appropriate practice. This will likely require ongoing investment in Rainbow competency training for health workforces, which would ideally build upon foundational knowledge delivered through various health professional educational preparation programmes.3537

Te Pae Tata appropriately identifies the need for Rainbow voices to be central to future service design and delivery initiatives. Some initiatives are already underway, including at Pegasus Health Primary Health Organisation.38 A key point in future service planning will be ensuring opportunities are provided for the full diversity of Rainbow voices to contribute. An added complication is that not all Rainbow people link these identities to their health and wellbeing needs.39


Conclusion

Te Pae Tata promises a ‘new health system’ and improved health outcomes for Rainbow people. Although this plan provides welcome recognition of inequity, it offers a limited, generalised view on how to improve health for Rainbow people. More specific and detailed action plans on how equity might be achieved are required.


Data availability

The primary source of data for this paper are published in academic literature.


Conflicts of interest

The authors declare no conflicts of interest.


Declaration of funding

This research did not receive any specific funding.



References

[1]  Fraser G, Brady A, Wilson MS. Mental health support experiences of rainbow rangatahi youth in Aotearoa New Zealand: results from a co-designed online survey. J R Soc N Z 2022; 52 472–89.
Mental health support experiences of rainbow rangatahi youth in Aotearoa New Zealand: results from a co-designed online survey.Crossref | GoogleScholarGoogle Scholar |

[2]  Adams J, Asiasiga L, Neville S. The alcohol industry—A commercial determinant of poor health for Rainbow communities. Health Promot J Austr 2022; 1–7.
The alcohol industry—A commercial determinant of poor health for Rainbow communities.Crossref | GoogleScholarGoogle Scholar |

[3]  Te Whatu Ora & Te Aka Whai Ora. Te Pae Tata: Interim New Zealand Health Plan. Wellington, New Zealand: Te Whatu Ora & Te Aka Whai Ora; 2022.

[4]  Little A. Govt delivers more wellbeing support to Rainbow young people. 2021. Available at https://www.beehive.govt.nz/release/govt-delivers-more-wellbeing-support-rainbow-young-people

[5]  Hughes AJ, Saxton PJ. Thirty years of condom-based HIV prevention by gay men in New Zealand. N Z Med J 2015; 128 19–30.

[6]  Institute of Medicine. The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: The National Academies Press; 2011.

[7]  Surace A, Riordan BC, Winter T. Do New Zealand sexual minorities engage in more hazardous drinking than non-sexual minorities? Drug Alcohol Rev 2019; 38 519–22.
Do New Zealand sexual minorities engage in more hazardous drinking than non-sexual minorities?Crossref | GoogleScholarGoogle Scholar |

[8]  Fraser B, Chisholm E, Pierse N. “You’re so powerless”: Takatāpui/LGBTIQ+ people’s experiences before becoming homeless in Aotearoa New Zealand. PLoS One 2021; 16 e0259799
“You’re so powerless”: Takatāpui/LGBTIQ+ people’s experiences before becoming homeless in Aotearoa New Zealand.Crossref | GoogleScholarGoogle Scholar |

[9]  Pihama L, Green A, Mika C, et al. Honour Project Aotearoa. Hamilton, Aotearoa: University of Waikato; 2020.

[10]  Adams J, Asiasiga L, Neville S. Drinking cultures of rainbow New Zealanders. Wellington, New Zealand: Health Promotion Agency; 2019.

[11]  Neville S, Henrickson M. Perceptions of lesbian, gay and bisexual people of primary healthcare services. J Adv Nurs 2006; 55 407–15.
Perceptions of lesbian, gay and bisexual people of primary healthcare services.Crossref | GoogleScholarGoogle Scholar |

[12]  Tan KKH, Carroll R, Treharne GJ, et al. “I teach them. I have no choice”: Experiences of primary care among transgender people in Aotearoa New Zealand. N Z Med J 2022; 135 59–72.

[13]  Stats NZ. 2023 Census: Final content report. Wellington, New Zealand: Stats NZ Tatauranga Aotearoa; 2021.

[14]  Stats NZ. LGBT+ population of Aotearoa: Year ended June 2021. 2022. Available at https://www.stats.govt.nz/information-releases/lgbt-plus-population-of-aotearoa-year-ended-june-2021/

[15]  World Health Organization. Social determinants of health. 2022. Available at https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1

[16]  Veale J, Byrne J, Tan K, et al. Counting ourselves: The health and wellbeing of trans and non-binary people in Aotearoa New Zealand. Hamilton, New Zealand: University of Waikato; 2019.

[17]  Fraser B, Jiang T, Cordue H, et al. Housing, instability, and discrimination amongst Takatāpui/LGBTIQ+ youth in Aotearoa New Zealand. Youth 2022; 2 339–51.
Housing, instability, and discrimination amongst Takatāpui/LGBTIQ+ youth in Aotearoa New Zealand.Crossref | GoogleScholarGoogle Scholar |

[18]  Fenaughty J, Ker A, Alansari M, et al. Identify survey: community and advocacy report. Identify Survey Team; 2022.

[19]  Bal V, Divakalala C. Community is where the knowledge is: The Adhikaar report. Adhikaar Aotearoa; 2022.

[20]  Adams J, Asiasiga L, Neville S. Justifications for heavy alcohol use among gender and sexually diverse people. Glob Public Health 2022; 17 2018–33.
Justifications for heavy alcohol use among gender and sexually diverse people.Crossref | GoogleScholarGoogle Scholar |

[21]  Adams J, Neville S. Enhancing the inclusion of gender and sexually diverse populations in evaluation: reflections grounded in practice. Eval J Australas 2021; 21 189–205.
Enhancing the inclusion of gender and sexually diverse populations in evaluation: reflections grounded in practice.Crossref | GoogleScholarGoogle Scholar |

[22]  Adams J, Coquilla R, Montayre J, et al. Views about HIV and sexual health among gay and bisexual Filipino men living in New Zealand. Int J Health Promot Educ 2021; 59 342–53.
Views about HIV and sexual health among gay and bisexual Filipino men living in New Zealand.Crossref | GoogleScholarGoogle Scholar |

[23]  Adams J, Coquilla R, Montayre J, et al. Knowledge of HIV pre-exposure prophylaxis among immigrant Asian gay men living in New Zealand. J Prim Health Care 2019; 11 351–8.
Knowledge of HIV pre-exposure prophylaxis among immigrant Asian gay men living in New Zealand.Crossref | GoogleScholarGoogle Scholar |

[24]  Neville S, Adams J. Views about HIV/STI and health promotion among gay and bisexual Chinese and South Asian men living in Auckland, New Zealand. Int J Qual Stud Health Well-being 2016; 11 30764
Views about HIV/STI and health promotion among gay and bisexual Chinese and South Asian men living in Auckland, New Zealand.Crossref | GoogleScholarGoogle Scholar |

[25]  Betts D, Maidment J, Evans N. Hidden and ignored: older sexual and gender minorities in New Zealand. Soc Work Soc Sci Rev 2020; 21 94–109.
Hidden and ignored: older sexual and gender minorities in New Zealand.Crossref | GoogleScholarGoogle Scholar |

[26]  Kushner B, Neville S, Adams J. Perceptions of ageing as an older gay man: a qualitative study. J Clin Nurs 2013; 22 3388–95.
Perceptions of ageing as an older gay man: a qualitative study.Crossref | GoogleScholarGoogle Scholar |

[27]  Neville S, Kushner B, Adams J. Coming out narratives of older gay men living in New Zealand. Australas J Ageing 2015; 34 29–33.
Coming out narratives of older gay men living in New Zealand.Crossref | GoogleScholarGoogle Scholar |

[28]  Lucassen MFG, Clark TC, Moselen E, et al. Youth’12 The health and wellbeing of secondary school students in New Zealand: Results for young people attracted to the same sex or both sexes. Auckland, New Zealand: The University of Auckland; 2014.

[29]  Clark TC, Lucassen MFG, Bullen P, et al. The health and well-being of transgender high school students: Results from the New Zealand Adolescent Health Survey (Youth’12). J Adolesc Health 2014; 55 93–9.
The health and well-being of transgender high school students: Results from the New Zealand Adolescent Health Survey (Youth’12).Crossref | GoogleScholarGoogle Scholar |

[30]  Tan KKH, Yee A, Veale JF. “Being trans intersects with my cultural identity”: Social determinants of mental health among Asian transgender people. Transgend Health 2022; 7 329–39.
“Being trans intersects with my cultural identity”: Social determinants of mental health among Asian transgender people.Crossref | GoogleScholarGoogle Scholar |

[31]  Adams J, Neville S. Exploring talk about sexuality and living gay social lives among Chinese and South Asian gay and bisexual men in Auckland, New Zealand. Ethn Health 2020; 25 508–24.
Exploring talk about sexuality and living gay social lives among Chinese and South Asian gay and bisexual men in Auckland, New Zealand.Crossref | GoogleScholarGoogle Scholar |

[32]  Roy R, Greaves LM, Peiris-John R, et al. Negotiating multiple identities: Intersecting identities among Māori, Pacific, Rainbow and Disabled young people. Auckland, New Zealand: The Youth19 Research Group, The University of Auckland and Victoria University of Wellington; 2020.

[33]  King-Finau T, Archer D, Fenaughty J, et al. The health and wellbeing of takatāpui and rainbow young people who have been involved with Oranga Tamariki. Auckland, New Zealand: The Youth19 Research Group, The University of Auckland and Victoria University of Wellington; 2022.

[34]  Adams J, McCreanor T, Braun V. Doctoring New Zealand’s gay men. N Z Med J 2008; 121 11–20.

[35]  Gamble Blakey A, Treharne GJ. Overcoming barriers to transgender healthcare education in Aotearoa New Zealand. N Z J Educ Stud 2019; 54 357–66.
Overcoming barriers to transgender healthcare education in Aotearoa New Zealand.Crossref | GoogleScholarGoogle Scholar |

[36]  Treharne GJ, Blakey AG, Graham K, et al. Perspectives on expertise in teaching about transgender healthcare: a focus group study with health professional programme teaching staff and transgender community members. Int J Transgend Health 2022; 23 334–54.
Perspectives on expertise in teaching about transgender healthcare: a focus group study with health professional programme teaching staff and transgender community members.Crossref | GoogleScholarGoogle Scholar |

[37]  Streed Jr CG, Navarra M, Klein J. Advancing undergraduate medical education regarding the care of transgender and gender diverse persons and communities. Perspec Med Educ 2022; 11 306–8.
Advancing undergraduate medical education regarding the care of transgender and gender diverse persons and communities.Crossref | GoogleScholarGoogle Scholar |

[38]  Hall M. Pegasus steps up with rainbow care. New Zealand Doctor; 2022. Available at https://www.nzdoctor.co.nz/article/news/pegasus-steps-rainbow-care

[39]  Adams J, Braun V, McCreanor T. Gay men talking about health: are sexuality and health interlinked? Am J Mens Health 2012; 6 182–93.
Gay men talking about health: are sexuality and health interlinked?Crossref | GoogleScholarGoogle Scholar |