Introduction
The concept of resilience is becoming increasingly prevalent in research focused on lesbian, gay, bisexual, transgender, and queer (LGBTQ) health. Though there is no widely agreed-upon definition of resilience, it commonly refers to the ability to withstand or overcome significant stress or adversity [
1]. Evidence supports the notion that LGBTQ populations’ health outcomes are not necessarily a result of intrinsic individual-level characteristics indicating a lack of resilience; rather, health inequities and poor health outcomes among LBGTQ populations are a result of the adversity experienced by gender and sexually minoritized populations [
2,
3]. For example, the ways in which LGBTQ health is often conceptualized and measured from a deficit-focused framework can have significant implications for health care access and uptake among LGBTQ populations, as the following section will discuss. LGBTQ health research has an important role to play in shifting the way that LGBTQ health is understood and measured in health policy and practice, which in turn has significant implications for health promotion strategies targeted at keeping LGBTQ populations healthy across the life course. The following section offers an overview of the key considerations in both understanding and measuring LGBTQ health.
Background
The health needs and experiences of LGBTQ populations have generally been rendered invisible in mainstream health care systems and policies [
4,
5]. This is, in part, because LGBTQ health has traditionally been understood through a heteronormative framework whereby the health needs and experiences of LGBTQ populations are assumed to be similar to those of their age-matched heterosexual and/or cisgender peers [
4,
6,
7]. The invisibility of LGBTQ health needs and experiences has significant implications in terms of the provision of evidence-based, culturally competent health care. For example, heterosexist institutional systems, including health care systems, are comprised of heteronormative and cis-normative foundations, in that they presume that an individual is both heterosexual and cisgender, meaning that a persons’ gender identity is congruent with their sex assigned at birth (i.e. not transgender). These presumptions contribute to what Bauer et al. describe as the informational and institutional erasure of trans people in health care systems, which, in turn, results in systemic barriers to care [
5]. For example, the Virginia Transgender Health Initiative Study found that the health care system was the most commonly cited area where transgender individuals experienced discrimination [
8]. A study of LGBTQ patients’ experiences with medical intake forms found that the language and structure of intake forms tended to be overwhelmingly heteronormative and cis-normative, and thereby alienating to LGBTQ populations whose identities and lived experiences were not reflected in the forms [
9]. These experiences of discrimination and informational and institutional erasure [
5] can affect the ways in which LGBTQ populations choose to access or avoid health care services [
4,
10,
11].
Public health policy and programming interventions have traditionally focused on individual-level indicators of health and on reducing the risk for negative health outcomes by changing individual, ‘lifestyle’ behaviour such as diet, exercise, and drug and alcohol use [
4]. While not unique to public health policy and programming for LGBTQ populations, individual-level focus also contributes to the erasure and invisibility of LGBTQ health needs and experiences, which are heavily shaped by broader structural, systemic and social determinants of health [
4]. For example, existing LGBTQ health research has demonstrated that social stigma, discrimination and victimization experienced by LGBTQ populations may affect uptake rates of preventative health screening programs and health care services [
12‐
14]. It is equally important to note that LGBTQ populations may also experience negative determinants of health such as homelessness, social exclusion and poverty at higher rates than their age-matched heterosexual and/or cisgender peers [
15‐
17]. The emphasis on individual-level determinants of health therefore obscures the broader structural and social determinants of LGBTQ health. Moreover, similar to non-LGBTQ populations, the overemphasis on individual-level determinants of health obscures the ways in which population-based supports work to reinforce the resilience demonstrated by LGBTQ populations and offer potential inroads for targeted health promotion strategies. For example, Herrick et al. argue that population-based initiatives that facilitate ‘coming out’ without fear of marginalization or violence are central to promoting the health of LGBTQ populations across the life course [
3].
LGBTQ health research has a significant role to play in shifting how LGBTQ health is understood and measured, and, more specifically, the ways in which health research evidence is used to inform health policy and practice. However, given the longstanding focus on the risks for poor health outcomes among LGBTQ populations, including rates of sexually-transmitted infections (STI) and human immunodeficiency virus (HIV) infection, smoking, obesity and depression/suicidal ideation [
18‐
20], a conceptual shift toward health-promoting LGBTQ research approaches is warranted. While deficit-focused health research is critical in the identification, mitigation and treatment of poor health outcomes among LGBTQ populations, it can also serve to reinforce negative perceptions of LGBTQ health. Moreover, deficit- and risk-focused research on LGBTQ health obscures the ways in which LGBTQ populations maintain their own health and avoid negative health outcomes. In response to the overemphasis on health research that takes as its starting point the risks and deficits among LGBTQ populations, health researchers have recently called for a shift in the focus of LGBTQ health research toward a more holistic understanding of LGBTQ health across the life course [
21‐
23]. In this regard, it is important to explore LGBTQ health from a life course perspective, which considers the historical and social contexts that shape LGBTQ experiences [
24]. For example, LGBTQ individuals who came of age when homosexuality was considered a psychiatric disorder or an illegal behaviour have very different experiences than younger LGBTQ individuals [
24]. Moreover, there is an urgent need to move away from risk- and deficit-focused approaches toward strengths-based approaches to measuring and understanding LGBTQ health [
25‐
27].
The emergence of health promotion approaches provides a promising conceptual shift in understanding and addressing LGBTQ health needs [
28‐
30]. According to the World Health Organization, health promotion approaches focus on the “…process of enabling people to increase control over, and improve, their health”, which includes “a wide range of social and environmental interventions” [
31]. It is important to note that health promotion recognizes the significance of both modifiable and non-modifiable determinants of health [
32,
33] and emphasizes upstream, preventative approaches, which include the development of healthy public policy, in contrast to deficit-focused approaches [
32]. Importantly, health promotion approaches have the potential to contribute to culturally and contextually meaningful health resources, which can contribute to resilience [
34] among LGBTQ populations. Recognizing, rendering visible, and appropriately measuring the determinants of LGBTQ health and wellbeing is critical to the development of culturally competent health care services, systems, and policies for LGBTQ populations [
21,
35].
Current study
This paper draws on the findings of a recent scoping review, which sought to answer the following research question: what strengths-based approaches have been used to understand and measure LGBTQ health? The scoping review is part of a broader program of research on pathways to health among LGBTQ populations in Nova Scotia, Canada. Currently, there is no available data on the percentage of the population of Nova Scotia that identifies as LGBTQ and no baseline measurement of LGBTQ health in Nova Scotia. This is particularly concerning given that populations in the Atlantic region, including Nova Scotia, tend to have worse health outcomes than populations living in other parts of Canada [
36]. As such, this program of research seeks to understand, measure and thereby render visible the health needs, outcomes and experiences of LGBTQ populations in Nova Scotia from a strengths-based perspective.
This paper is a broader exploration of resilience, which emerged as a key conceptual framework in our scoping review. Specifically, the purpose of this paper is to explore the utility of resilience as a conceptual framework in understanding and measuring LGBTQ health, with reference to the scoping review findings. Our findings have important implications for future strength-based research on LGBTQ health both in Nova Scotia and more broadly.
Methods
Scoping reviews are a useful method of retrieving literature on a specific topic of interest or identifying gaps in the existing literature [
37]. Our scoping review followed the methodology set out by Arksey and O'Malley, which involves six stages: identifying the research question; searching for relevant studies; study selection; charting the data; collating, summarizing, and reporting the results; and consulting with stakeholders. [
37]. The focus of our scoping review was on identifying strengths-based approaches to LGBTQ health research. The key terms for the scoping review were determined by a community advisory committee comprised of LGBTQ community members, representatives from LGBTQ organizations, health researchers and a health reference librarian. In total, the scoping review, which was conducted in October 2014, yielded 1,855 de-duplicated results, of which 105 met the inclusion criteria (see Table
1 for the databases, key terms, and inclusion and exclusion criteria). Given the Canadian context of our research, we included only peer-reviewed strengths-based studies on LGBTQ health conducted in Canada, the United States, the United Kingdom, Australia and New Zealand in our review. A number of key conceptual and methodological frameworks were identified in the scoping review, including resilience, intersectionality, community-based participatory research, social ecology, and life course approaches. This paper will focus specifically on how the concept of resilience was defined and measured in studies included in the scoping review to examine its utility as a conceptual framework for strengths-based research on LGBTQ health.
Table 1
Scoping review search strategy
| Two spirit, LGB*, Lesbian*, Gay*, Transgender*, Transsexual*, homosexual, intersex*, gender minorit*, Queer*, Genderqueer, Gender varian*, Trans gender*, Trans sexual*, sexual minorit* | Resilienc*, Protective factor*, Health promot*, Health protect*, Life course*, Harm reduction, Health predict*, Social determinants of health, health disparities, Health status | Data collection, Survey*, Model*, Framework*, Measure*, Tool*, Assess*, Epidemiology, Module, Evaluat* |
Databases | PubMED; CINAHL; PsychINFO; Gender Studies Database; History of Science, Technology and Medicine |
Inclusion | Published in English; Peer-reviewed; Academic journal; Primary study; study conducted in the US, UK, Australia, New Zealand or Canada; Strengths-based/health promotion perspective |
Exclusion | Published in language other than English; Non Peer-reviewed; Book, dissertation, conference abstract etc.; Not a primary study; Study conducted in country other than US, UK, Australia, New Zealand or Canada; deficit/risk-focused perspective |
Time Frame | The scoping review was conducted in October 2014. All included results were published before then. We did not limit our search using a start year. |
Conclusions
Implications for future research
The purpose of this paper was to explore the utility of resilience as a conceptual framework in understanding and measuring the health of LGBTQ populations based on a scoping review of LGBTQ health literature from a strengths-based, health promotion perspective. The fact that there is no clearly agreed-upon definition of resilience presents a challenge in determining its utility for strengths-based LGBTQ health research. Further, the tendency for resilience to focus on individual-level factors or to be characterized as a set of inherent intrapersonal traits is particularly concerning in light of the ways in which privileging the individual over the structural and the social has contributed to the invisibility and erasure of LGBTQ health needs and experiences within health policy and health care systems. Broader definitions of resilience (see, for example, Ungar et al. [
34]), which take into account structural, social, and individual determinants of health are more consistent with the ecological health promotion model. There is also a notable absence of baseline and longitudinal data on resilience, and future research on the utility of resilience in measuring LGBTQ health should consider how resilience develops and changes across the life course.
Given the diversity of factors potentially contributing to resilience as cited in the articles included in our scoping review, it is difficult to determine which factors are most relevant to promoting the health of LGBTQ populations in particular contexts, such as Nova Scotia. As such, in order to utilize resilience in understanding and measuring LGBTQ health, our health research approaches must first determine the key factors that contribute to resilience among LGBTQ populations. The debate on whether resilience models should be LGBTQ-specific is also critical in moving forward. LGBTQ populations have unique lived experiences of adversity and discrimination based on their interactions within heteronormative and cis-normative health and social care systems, which influence their pathways to health across the life course. In addition, LGBTQ populations may also have unique resilience factors that can promote and enhance health across the life course which need to be better understood and measured [
65]. As such, the ongoing focus and utility of individual-level, mainstream, heteronormative and cis-normative models of resilience in understanding and measuring LGBTQ health is questionable. Finally, models of resilience must reflect and incorporate intersectionality. Incorporating an intersectional lens acknowledges the complex intersecting and compounding nature of marginalization, oppression, risk factors and their subsequent impacts of LGBTQ health across the life course.
In comparison with interventions focused on mitigating health risks, the potential impact of LGBTQ health interventions focused on promoting resilience in relation to health outcomes is promising. As such, there is a need for more comprehensive theoretical and conceptual models that include resilience in the future design of health promotion strategies. However, while we fully acknowledge the resilience of LGBTQ populations, we argue that there is much work to be done before it can be truly useful as a concept in measuring LGBTQ health.
Limitations
The findings of our scoping review presented here and the subsequent conceptual mapping of resilience are subject to potential limitations. The databases used for this study were searched for English language, peer-reviewed, published articles only. Therefore, relevant data presented in a language other than English or that is not available in peer-reviewed academic literature may have been excluded. Given that our research is based in the context of Nova Scotia, Canada, only studies conducted in Canada, the United States, the United Kingdom, Australia and New Zealand were included in our scoping review. As such, there may be studies on resilience based in other contexts that were excluded. Further, given that this paper draws specifically on the articles included in the scoping review, there may be other research on resilience among LGBTQ populations that is not represented.
Significance
This paper builds on existing knowledge on LGBTQ health by providing a review of studies that explore resilience among LGBTQ populations. Given the traditional emphasis on health risks and deficits among LGBTQ populations, our emphasis on strengths-based approaches to LGBTQ health, including resilience, is significant. Moreover, this paper builds on the broader literature on resilience by focusing on LGBTQ populations, which highlights the need to consider how resilience might be understood and measured differently for LGBTQ populations.
It is essential that we continue theoretical and conceptual exploration of resilience among LGBTQ populations. A more comprehensive understanding of LGBTQ resilience will allow us to gain a more comprehensive and holistic understanding of pathways to health among LGBTQ populations. It will also provide insight on relevant health interventions and health promotion strategies aimed at advancing LGBTQ health across the life course. Exploring approaches to LGBTQ health that are designed to not only address vulnerabilities but also to incorporate and support resilience has the potential to have a significant impact on the health outcomes of LGBTQ populations.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
EC participated in the study design, participated in conducting the scoping review, analyzed the scoping review data, and drafted and revised the manuscript. JG conceived the study, participated in the study design and conducting the scoping review, and revised the manuscript. Both authors read and approved the final manuscript.