Subgroup-specific services or universal health coverage in LGBTQ+ health care?
Authors: Yudit Namer, Oliver Razum
Journal: The Lancet Public Health (2019)

Designing public services for excluded groups comes with a crucial question: is it better to create group-specific and consequently segregated services catering to the unique needs of population subgroups? Or should the inclusivity and intersectionality of existing services be increased instead by opening the care offers to all members of the community—the very idea of universal health coverage? This question is especially relevant in the care of people in the lesbian, gay, bisexual, trans, queer (LGBTQ+) community. The Lancet Public Health's March Editorial1The Lancet Public HealthLGBT: the vital fight for the right to health.Lancet Public Health. 2019; 4: e116Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar reflects on anti-LGBTQ+ laws and their effect on health. In doing so, it inadvertently illustrates some of the disadvantages of subpopulation-specific health services: LGBTQ+ people might self-exclude from such services when faced with the risk of criminalisation;2Kavanagh M Baral S Milanga M Sugarman J Biometrics and public health surveillance in criminalised and key populations: policy, ethics, and human rights considerations.Lancet HIV. 2019; 6: e51-e59Summary Full Text Full Text PDF Scopus (8) Google Scholar group-specific services developed with an anti-LGBTQ+ agenda might be detrimental to health, as in the case of conversion therapy; and targeting LGBTQ+ people as at-risk for HIV cultivates anti-LGBTQ+ laws.1The Lancet Public HealthLGBT: the vital fight for the right to health.Lancet Public Health. 2019; 4: e116Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar Although intended to be safe spaces for marginalised groups, without critical reflection on LGBTQ+ specific health services might run the risk of increasing service users' vulnerability to further victimisation. Debates surrounding prison services for trans people serve as a further example.3The EconomistA tough cell: a transgender wing seeks to resolve a clash of prisoners' rights.https://www.economist.com/britain/2019/03/09/a-transgender-wing-seeks-to-resolve-a-clash-of-prisoners-rightsDate: March 7, 2019Date accessed: April 26, 2019Google Scholar All discussions regarding the criminalisation of LGBTQ+ people aside, creating trans-specific prisons means putting one marker of diversity (gender identity) above any other attribute that authorities consider when placing a prisoner, such as personal history, physical and mental health, or type of offence. When LGBTQ+ prisons were debated in Turkey, with the premise and promise of security, LGBTQ+ prisoners mostly voiced an interrelated fear of first isolation, because it would force LGBTQ+ people to serve their time in a place far from their place of residence, making it difficult for friends and relatives to visit; and second stigma, because it would automatically identify them as LGBTQ+ to family members and everyone within the prison system.4Göksel D Aiding Turkey's gay inmates.The New York Times. May 26, 2014; https://www.nytimes.com/2014/05/27/opinion/aiding-turkeys-gay-inmates.htmlDate accessed: April 26, 2019Google Scholar Such debates manifest the need for critical reflection and research dedicated to the essential question of subgroup-specific versus inclusive services. The risk of transmitting HIV, which the Editorial1The Lancet Public HealthLGBT: the vital fight for the right to health.Lancet Public Health. 2019; 4: e116Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar chooses to underline above other health risks, and which might underlie the argument for specialised services, is only one component of the right to health indicated in its title. Being at risk of immediate physical and psychological danger due to stigmatisation and isolation is certainly a public health concern just as grave. With the encampment and torture of LGBTQ+ people in Chechnya5Martin K No justice for Chechnya's anti-gay purge victims. Human Rights Watch, April 5, 2018https://www.hrw.org/news/2018/04/05/no-justice-chechnyas-anti-gay-purge-victimsDate accessed: April 26, 2019Google Scholar and the forced sterilisation of trans people in Japan,6The LancetCoercive sterilisation of transgender people in Japan.Lancet. 2019; 393: 1262Scopus (5) Google Scholar the notion of group-specific services becomes even more paradoxical. Securing and promoting dignity should be the aim of any public service. Diversity-sensitive universal health coverage, rather than group-specific services, seems to be the best pathway to reaching this aim. We declare no competing interest. LGBT: the vital fight for the right to healthIn this issue of The Lancet Public Health, Annick Bórquez and colleagues present findings from a study of HIV prevention among transgender women sex workers in Lima, Peru. The study follows a 2014 policy initiative aimed to introduce HIV prevention strategies for key at-risk populations. The authors report that implementation of test and offer, tailored condom promotion, and pre-exposure prophylaxis could avert nearly 50% of new infections over 10 years. The findings are a part of a larger mixed-methods study that has already informed development of a comprehensive HIV care and prevention plan specifically designed for transgender women in Peru. Full-Text PDF Open Access