Anna Ponjoan: “Gender identity must be studied to reduce health inequities”

We interviewed the IDIAPJGol’s USR Girona researcher, who explains the lines of research that she is carrying out in the field of gender identity and sexual orientation and their relationship with health care

Managing gender identity and sexual orientation in research is essential to reduce health inequities. This is the opinion of the researcher at the IDIAPJGol’s Girona Research Support Unit, Anna Ponjoan, who is leading three projects aimed at discovering the perceptions and health needs of the LGTBIQA+ people. One of these projects, L-HEALTH, focused on addressing the health needs of lesbians, has been presented this week in Barcelona.

What research projects are you carrying out in your group in relation to the health of LGTBIQA+ people?

We are doing a qualitative study in Girona, which is being carried out by the nurse of the Primary Health Centre of Maçanet de la Selva, Alícia Llamazares, and I, in which we address the health needs of transsexual people in Primary Care. We have seen that on many occasions it is difficult to reach this group, who often feel mistreated or prejudged by professionals.

Another project we are working on is the IRIS, financed by a grant from the FIS, of the Carlos III Health Institute. It is about building a cohort of LTGBQ people from Catalonia based on SIDIAP. There are many people who are belongs to this collective who have felt discriminated against or uncomfortable when they have been attended in their primary care center. This makes them use the Primary Care services less. In the study we focused on cardiovascular health. In the case of having risk factors, such as hypertension or hypercholesterolemia, it is necessary to have periodic control at the CAP, and if LTGBIQA+ people do not go to their health center because they do not feel comfortable, the control of cardiovascular risk factors could worsen. We want to compare the situation of cardiovascular health and the adherence to treatments between people in this group and the general population.

How do you select the sample?

Sexual orientation is almost never asked and, therefore, this information is not included in the SIDIAP [the data base of the people attended at the Catalan Primary Care]. We have not identified our study population, so we must build a cohort of LTGBQ people. We will do this with a somewhat complicated sample selection method called responder-driven sampling, a technique halfway between snowball and random sampling, which allows us to obtain representative samples of poorly accessible populations, hidden populations. First, we select about ten LTGBQ people, each of whom answers a survey and sends it to three other people in the group and so on. To identify the first participants and disseminate the study, we are contacting various associations throughout the country.

What relevance does this project have? Are other similar studies being carried out?

There are very few works on this matter. Research on health among LTGBIQA+ people is very insufficient, and the little that exists focuses on the group of men who have sex with other men. Furthermore, the topic of these investigations is usually sexual health and mental health. I was interested in studying other topics as well. Assuming that the only areas in which sexual orientation and gender identity influence are sexual health and mental health is very bold.

Another project that you are also carrying out is L-HEALTH, which was presented publicly on April 22nd. What does it consist of?

It is a research that aims to identify inequalities in access to health among lesbians treated in Primary Care and the attitudes of professionals regarding addressing the health needs of the group, taking into account their specificities and experiences. Our goal is to improve clinical practice based on the perceptions of lesbians and of health professionals, who do not receive training in schools on how to address the health problems of these people. This is an area in which very little research is done and it is difficult for professionals to achieve the necessary knowledge to carry out adequate practice. With L-HEALTH we will also develop a cohort of lesbians, which we will compare with a sample of the general population, following the same model that we use for the IRIS.

From the results we obtain from the qualitative study with lesbians and from the one we do with professionals, as well as those we identify in the cohort, we will be able to take a snapshot of the health status of the lesbian community and we will be able to identify what the key aspects are, where they are located. the greatest differences in addressing the health needs of lesbians in relation to the general population and what needs professionals have expressed. With this information we can design specific training for professionals. Here we have the experience of Sida Studi, which is one of the entities that participate in L-HEALTH, which has a lot of experience in providing training. We will validate this training proposal in a pilot in which thirty or forty professionals will participate. The essential idea of the project is to identify health inequities and act as a lever for change to improve clinical practice when caring for lesbians in primary care consultations.

What results do you hope to find in the study? What hypotheses have you raised?

The starting hypothesis is that when a person enters the Primary Care centre, it is assumed that they always have a heteronormative profile. This can cause discomfort among people who do not respond to that pattern. There is another interesting topic, and that is that I think it is necessary to ask about sexual orientation, but you must know when it is appropriate to do so and when it is not, and also how to do it.

Another thing we also address with L-HEALTH is intersectionality, considering other sociodemographic and cultural aspects. The impacts that structural violence has on health are not only determined by sexual orientation and gender, but also by other factors such as the country of origin or the neighborhood of residence.

What does it mean for you to receive European funding for this project?

It means that we have resources to do excellent research. It allows us, for example, to hire two people who are beginning research in this area. It also connects us with a wide European research network.

What are the main benefits of knowing better the health of LGTBIQA+ people for the community and health professionals?

Putting sexual orientation and gender identity on the table in healthcare and research makes it possible to make health inequalities visible and break them down. If we continue to silence it, we perpetuate clinical practices that are not the most appropriate for these people.

As far as research is concerned, it is important to carry out excellent practice. This is an area that has been studied very little and it is important that the new knowledge we generate is rigorous to improve clinical practice. Without scientific evidence it is very difficult to improve things.

How important is the LGTBIQA+ perspective in the design and implementation of research projects?

It is essential. It can’t be done any other way. There is a part that goes beyond sex, and that is that you end up living life and seeing reality from a position other than the heterocisnormative one. For example, being a lesbian is not just having sex with women, it implies a different way of living and seeing things.

However, the needs of lesbian, gay, transgender people, and the rest of the people who identify with each of the letters of the acronym are very different. How to address these diverse needs through research?

Indeed, their needs are very different, and we also find differences within each letter. However, we need to approach these differences little by little. From now on, we will tend to carry out increasingly limited research projects, to identify the health needs of each group. But before separating, we must have made a broader approach.