Warning voices in a policy vacuum: professional accounts of gay men's health in Aotearoa New Zealand.

• Author: Adams, Jeffery

Abstract

Internationally, public health policy and practice are increasingly recognising and focusing on gay men's health issues beyond HIV/AIDS. Against this background we consider how gay men's health is understood and considered in Aotearoa New Zealand, including identification of problems, aetiology and possible solutions. Semi-structured interviews with key informants involved in diverse professional roles in areas related to health for gay men were undertaken and three overarching themes identified. First, informants identified gay men's health as a legitimate area of concern within health policy. Second, they framed gay men's health in biopsychosocial terms, but highlighted socio-political factors. Third, the informants suggested that broad health-promoting strategies, coupled with targeted strategies, are needed to improve gay men's health. However, informants confirmed that there is very little mainstream policy interest in gay men's health; similarly, they identified little interest in broader health issues within the gay community. These findings contrast with many international settings where health for gay men is an emerging area of policy concern and health promotion activity, in both mainstream and gay-specific settings. We argue that the invisibility of gay men within health policy contributes to disempowering gay men, which is likely to contribute to continued health disparities for gay men. To conclude, the policy implications of these findings are discussed.

INTRODUCTION

Population approaches to promoting health and wellbeing have for some time recognised interrelated social determinants of health that influence the health of populations, including gender, the social characteristics of people's neighbourhood, and social inclusion/exclusion, such as that arising from racism (Pickett and Pearl 2001, Wilkinson and Marmot 2003, World Health Organization 2004). While health policy and research routinely evaluate the influence of factors such as age, sex, gender and ethnicity (Loue 1999), historically there has been much less concern within policy settings with issues of sexual identity and behaviour.

However, in recent times social approaches to health are increasingly taking account of sexual identity and behaviour (Ministerial Advisory Committee on Gay and Lesbian Health 2003). (2) One result of this is that internationally public health policy and practice are now recognising and focusing on gay men's health issues beyond HIV/AIDS and acknowledging other serious health issues for gay men (Guthrie 2004, Meyer 2001, Rofes 1998, Swan 2004). This recent shift is typically framed and justified with reference to a research literature that identifies areas of health disparities between gay men and the male population in general. Two areas of research illustrate the disparity in health. Firstly, the use of crystal methamphetamine, particularly in the United States, has been closely linked to sexual risk-taking and identified as an emerging health problem among some groups of gay men. (3) Secondly, the Christchurch Health and Development Study determined that non-heterosexual populations are an at-risk population for mental health problems (Fergusson et al. 2005, Fergusson et al. 1999). Predominantly homosexual males had an overall rate of mental health problems over five times the rate for exclusively heterosexual males, including suicide attempts (28.6% and 1.6% respectively) and suicide ideation (71.4% and 10.9%) (Fergusson et al. 2005).

These are, however, not the only areas where disparities between gay men and the general male population have been identified. For example, international research has identified disparities with respect to eating disorders (Russell and Keel 2002, Williamson 1999, Williamson and Spence 2001) and cigarette smoking (Gruskin and Gordon 2006, Ryan et al. 2001, Stall et al. 1999), while New Zealand research has identified disparities with respect to sexually transmitted infections (Saxton et al. 2002). These differentials support attention being paid to gay men's health and wellbeing issues and needs.

Gay men's health is an important policy and research field to demarcate. Internationally, this is provided by some policy development and health promotion activity, and a growing body of research about specific health issues faced by gay men. In New Zealand, while there has been a limited amount of research, health promotion activity and policy development with health issues of particular concern to gay men such as HIV/AIDS (Ministry of Health 2003), alcohol (Alcohol Advisory Council of New Zealand and Ministry of Health 2001), and, more recently, suicide prevention (Associate Minister of Health 2006), there has been no specific policy concern with the broader aspects of gay men's health (Adams et al. 2004). Nor have gay men been included as a general population category of concern in most health policy development.

Arguments for including the health needs of gay men within public health policy in New Zealand can be situated within a social rights discourse, in which everyone is entitled to health, and where there are societal obligations to provide some level of health care (Bole 1991, Gruskin and Tarantola 2002). This discourse is evident in New Zealand health policy through two key principles relating to the universality of health and on extra attention for the disadvantaged, as expressed in the New Zealand Health Strategy: "Good health and wellbeing for all New Zealanders throughout their lives"; and "An improvement in health status of those currently disadvantaged" (Minister of Health 2000). The continued lack of policy concern appears to reflect a negative positioning of gay populations, which remains a point of difference from other defined sub-populations such as Maori (Minister of Health and Associate Minister of Health 2006), Pacific peoples (Ministry of Health 2002b), younger (Ministry of Health 2002c) and older people (Ministry of Health 2002a), all of which are targeted within New Zealand health policy under the umbrella of "disadvantage".

Given the policy vacuum around gay men's health issues, it seems a reasonable assumption that an "authoritative" view of the state of gay men's health in New Zealand, and key issues to consider, will come from those professionally involved in health service provision to gay men. In this paper we examine how such professionals see the issues around gay men's health. How are the problems identified? What causal attributions are offered? What are the possible solutions? How can useful health promotion initiatives be developed? We conclude by considering the interview data and the findings within the context of public health policy environments in New Zealand and internationally, discussing why gay men's health is not currently a significant policy issue, and suggesting ways that gay men's health could be incorporated within mainstream health policy.

METHOD

A qualitative semi-structured interview method was used. Interviews were conducted with 11 participants, including people working in policy/management and health promotion positions in government and non-government settings, physicians in private practice, and other clinicians working in public health settings (see Table 1 for details of these positions). The number and diversity of participants were appropriate to the small exploratory study we were engaged in, where the aim was to gather a rich insight into the understandings of the field among professionals working in the area.

Informants were chosen using purposive sampling techniques on the basis of their involvement in gay men's health issues and to encapsulate diverse experiences in the area. Most of the informants were individuals known to the research team or people occupying specific roles in key organisations. Others were identified through recommendations made by people who had been interviewed. Nine of the informants were gay men. The data therefore comprise a mix of non-gay professionals reflecting on gay health issues from their professional perspective, and gay professionals providing personal and professional reflection on their community and gay health issues. Recruitment of informants continued until a diverse range of perspectives and expertise had been covered and interviews were no longer eliciting any substantive new insights. The data obtained and reported on in this paper reflect the views of these informants; they do not represent all possible views about gay men's health.

Interview questions sought to elicit informants' views on issues in gay men's health, including factors positively and negatively influencing health, relevant policies and health promotion activities, and research needs. All interviews were conducted in person by the first author. Interviews lasted between 45 and 95 minutes, depending on how much the participant had to say on the topic, and, with informants' consent, were audiotaped and transcribed. All data were anonymised, with participants choosing a professional identification for use in publications.

The data were thematically coded to identify repeated issues in participants' discussions of gay men's health. Thematic analysis is a useful analytic approach to look across an entire data set to find repeated patterns of meaning (Braun and Clarke 2006). It provides "thick descriptions" of the common elements of a number of accounts and displays the richness and diversity of participants' experiences, while respecting the integrity of particular stories (Denzin and Lincoln 1994, Patton 1990). Thematic analysis allows us to treats participants' stories as unproblematic tellings of experience, and it is particularly useful for providing a contextualising overview of the findings of research (Braun and...