Coming out: is the Mardi Gras still needed?

The Sydney Gay and Lesbian Mardi Gras has been an annual event on the streets of the city since 1978.1 The original purpose of this and other gay pride events in Australia and elsewhere was a public protest at negative social attitudes and antihomosexual legislation, and as part of an international day of action. It has expanded, in parallel with many other such events around the world, to become a festival to celebrate lesbian, gay, bisexual, transgender and intersex (LGBTI) culture. However, it retains elements of political activism regarding persistent social and legal inequalities. This focus is necessary, as long as disclosing a non-heterosexual orientation remains a question rather than a natural response for people who self-identify as LGBTI.

While legislative frameworks have largely been reformed under human rights and social equity principles over the past two decades,1 repeated negative public statements by high-profile individuals point to ongoing and pervasive homophobia in our society.2 These statements are often defended as legitimate free speech, yet they have far-reaching consequences, because the people they vilify as LGBTI individuals are highly sensitised to these negative attitudes. Further, because disclosure is often met with rejection, hostility or violence, the decision to “come out” must be very carefully considered and negotiated.3 Disclosure of sexual orientation has long been regarded as a positive step towards a healthy and secure identity;4 however, it may equally have negative consequences in oppositional social contexts.5 Disclosure to health care providers can be particularly challenging, given that generally providers do not ask about sexual orientation — despite most patients’ desire to disclose this information.6

Homophobic attitudes and discrimination contribute significantly to many health disparities experienced by LGBTI people. These include higher rates of depression and anxiety, self-harm and suicidality, misuse of harmful substances, violence and victimisation.7 For example, same-sex attracted young people attempt or commit suicide at rates far exceeding their heterosexual peers, and this is often related to, or occurs before, coming out.8 A higher prevalence of risk factors for cancer and cardiovascular disease and lower rates of preventive screening among LGBTI people are also of concern.9 Although disclosure to a sensitive health care provider has been found to improve screening rates,10 LGBTI people report difficulty in accessing providers who are sensitive and knowledgeable about the impact of homophobic discrimination on health.11

There is now widespread recognition that these health disparities constitute a critical public health issue. The Australian Psychological Society,12 Australian Medical Association,13 Public Health Association of Australia14 and a host of professional organisations in the United States and elsewhere have released position statements to this effect. The Australian national depression initiative, beyondblue, has developed an awareness campaign, for release in 2012, which aims to reduce the impact of discrimination on the mental health of this population (http://www.beyondblue.org.au). This campaign will include, among other strategies, encouragement of LGBTI people to seek help and the creation of an accessible list of LGBTI-sensitive mental health services. Finally, community responses are flourishing, such as the “It Gets Better” campaign, initiated in the US and launched in Australia in 2011 (http://www.igba.org.au). This campaign is designed to combat the risk of suicide among same-sex attracted and gender-questioning young people, using positive public messages and encouragement to seek support and community connection during the coming out process.

Individual health care providers have an obligation to be informed about the health issues faced by their LGBTI patients. Common neutral responses, such as a belief that sexual orientation is irrelevant within consultations,6 generate a lack of trust and fear of negative responses. There are guidelines for health care providers on how to sensitise their service to LGBTI patients, which include simple, cost-neutral methods.15 Health care providers can go further and assume a role in advocacy and become opinion leaders for social change. Lending support to an awareness campaign, challenging workplace discrimination or even marching in a Mardi Gras parade would be visible signs that this group of professionals wishes to help reverse health inequalities and create a safer society for LGBTI people. Once accomplished, coming out will no longer be an issue and the activism of Mardi Gras and LGBTI pride events can be consigned to history.