Not everyone in Canada experiences health care the same way. We know that certain groups face more negative experiences and outcomes with health-care services than others for simply being themselves. For example, 2SLGBTQIA+ communities in Canada experience health inequities related to accessibility of health care, quality of care, inclusivity and satisfaction of care. Disparities can be exacerbated based on identity and social position. The intersections between sexual minority, socio-economic status, gender and ethnicity can have compounding impacts on health disparities.
Unfortunately, the systems that perpetuate health disparities are operating exactly as designed. In 2019, the House of Commons released a report on the health of 2SLGBTQIA+ communities in Canada indicating that the health inequities of the community is partly due to the stigmatization and discrimination that they face in society. The marginalization from society impacts how we structure our systems, processes, health-care services and so much more.
Policies can help to address these health inequities. They can also perpetuate them. For about three decades, Canadian Blood Services (CBS) has had discriminatory policies against 2SLGBTQIA+ communities, such as banning blood donation from men who have sex with men. In September 2022, CBS removed its donor deferral policy that rejected blood and plasma donations from all sexually active men who have sex with men, and some trans people. Instead, it started screening everyone on sexual behaviours, regardless of their sexual orientation and access to gender-affirming care. Before this change, two people who engaged in the same sexual behaviours would be screened differently. One person would be allowed to donate while the other would be turned away because of their sexual orientation.
By not challenging these policies for so long, we cared more about upholding these systems of oppression and discrimination than we did about patient safety and increasing our critically low blood and plasma supply. As someone who lives in Canada, this should terrify you because it speaks volumes about our priorities, values and culture. Clearly not everyone in Canada is afforded the same treatment (both social and medical).
On May 10, 2024, CBS issued a historic apology to 2SLGBTQIA+ communities for past discriminatory policies that prevented many from donating blood. CBS acknowledges that these policies contributed to discrimination, homophobia, transphobia and human immunodeficiency virus (HIV) stigma.
So, are policy changes and apologies enough?
We know that medical mistrust from minority groups, such as Black and African-American people, is not uncommon. In some cases in the U.S., the mistrust resulted in denying the effectiveness of medication, such as the effectiveness of pre-exposure prophylaxis (PrEP), a medication used to reduce the chance of HIV transmission by 99 per cent, if taken properly. A policy change and an apology without true reconciliation cannot be enough. Past, present and future harms can stem from outdated policies; they perpetuate stigma and discrimination; they increase community mistrust in health care. Simply updating said policies and apologizing will not reverse these injustices.
This is not intended to “call out” but rather to “call on” CBS to take moral responsibility for its discriminatory action and take meaningful steps to rebuild and strengthen trust with the 2SLGBTQIA+ community. CBS has a truly noble cause and one that benefits everyone in Canada. We should all wish for it to succeed.
While it is great that it has intentions to gain trust from 2SLGBTQIA+ communities, true reconciliation requires that CBS work with the community to pave a path for anti-discriminatory work, not just for CBS, but also for other health-care organizations, systems and society. Its harm spanned beyond its organizational walls and thus its actions ought also to do the same.
Its harm spanned beyond its organizational walls and thus its actions ought also to do the same.
The good news is that CBS is now on the right path. Whether it stays on this path is yet to be determined. The Institute for Healthcare Improvement (IHI) outlines three steps to improve trustworthiness in health care, inspired by the work of Michelle Morse, M.D., and Bram Mispelwey, M.D., on the Healing ARC model, which addresses institutional racial inequities. The purpose of the IHI model is to rebuild and strengthen trust with communities and providers by:
- Acknowledging past breaches of trust
- Redressing and closing trust gaps in the present
- Building systems to strengthen trust for the future
Although the Healing ARC focuses on eliminating inequities in patient care for people of colour, IHI’s model expands on this by focusing on trust and emphasizes building systems to strengthen trust for the future. We can see that CBS’ public apology acknowledges past breaches of trust and discrimination (first step), and that it established a 2SLGBTQIA+ working group to redress and close the trust gaps in the present (second step). CBS has the opportunity to be an example of how organizations can change, and it has the moral obligation to support strengthening those systems that build future trust with 2SLGBTQIA+ communities (step 3). Building trust may result in an increase of blood donor base, reduce discrimination of 2SLGBTQIA+ communities in health care, and save lives. It’s a win-win-win.
I anticipate that CBS will show up to Pride events across Canada this year. If representatives do, they will likely experience tough conversations with members from 2SLGBTQIA+ communities stemming from valid feelings rooted in past discrimination. CBS can use this as an opportunity to humbly listen and engage in meaningful conversations.
I highly encourage CBS to think about the message it is sending and to fully understand the impact it has by simply being present at Pride events, including the potential to re-traumatize individuals that have had negative experiences with the health-care system.
The reality is that CBS does not have the resources, nor the organizational mandate, to eliminate all 2SLGBTQIA+ health inequities across Canada. Nor should it since this requires concerted efforts from partners across systems, governments, health-service delivery organizations and communities.
The steps outlined in the IHI model include “change ideas” to rebuild and strengthen trust with communities. In addition to implementing these ideas, CBS can also analyze the drivers of its organizational change, publicly share its organizational journey of learning and unlearning, and develop a guide with practical resources for other organizations embarking on equity, diversity and inclusion work centered on reducing health inequities for 2SLGBTQIA+ communities. These steps, of course, need to be done in tandem with the community and other partners. CBS can lead by example and support other organizations to also embark on their own healing journeys. This can serve as a basis to spread and scale practices that rebuild and strengthen 2SLGBTQIA+ trust in health care.
There is an alarming need to address systemic discrimination and inequities in patient care and access for 2SLGBTQIA+ communities. CBS, and other health organizations, have the opportunity and moral responsibility to build a better health system for 2SLGBTQIA+ communities.
We desperately need our health systems to change, and we know that change happens at the speed of trust. So, trust me when I tell you that 2SLGBTQIA+ communities need governments, systems and health-care organizations to step up and take action.
