Rainbow health in Aotearoa New Zealand – finally getting the attention it deserves?
Jeffery Adams
1 * , Stephen Neville 2
1 SHORE & Whāriki Research Centre, Massey University, PO Box 6137, Auckland 1141, New Zealand.
2 Te Pūkenga, PO Box 19400, Hamilton 3244, New Zealand.
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).
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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.1,9–12 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.22–24
Health inequity for Rainbow people is often impacted by other identities they hold – such as age (including younger and older),18,25–29 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.35–37
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.
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