Written by JhuCin Rita Jhang, Ph.D.
On 23 September 2021, a historical court ruling allowed a transgender woman to change the gender on her I.D. without proof of surgery. The verdict sparked joy and hope while intensifying the debate about transgender rights. Proponents of no-surgery-ID-change (免術換證) for transgender people were pleased. At the same time, the public, including many who have been supportive of same-sex marriage and tongzhi (同志, a commonly used Chinese term roughly equivalent to LGBTQ+) rights in general, have voiced concerns and even rejection, primarily due to the apprehension that “a person with a penis” could enter a female-only space, or that a transgender woman was or is still a man. Men should not be vying for limited resources reserved for women.
Regardless of whether or what surgery to request for a gender change on someone’s I.D., when transgender people’s health and women’s rights are being pitted against each other, both suffer in this forced dichotomy. And this controversy hints at a more significant problem of health issues facing tongzhi/LGBTQ+ people in Taiwan: they are either highly controversial, such as the no-surgery-ID-change, or woefully neglected, such as the general lack of basic routine health statistics and studies, the cis-heteronormative assumption in medical and health care services, and the resulting minority stress for tongzhi/LGBTQ+ that the cisgender-heterosexual majority could hardly grasp. Moreover, the cis-heteronormative assumption that everyone’s biological sex (which decides the sex assigned at birth) is aligned with that person’s gender identity (i.e., cisgender) and everyone is and should be heterosexual creates a veil that renders tongzhi/LGBTQ+ health issues invisible.
Invisibility is an old problem. For example, the lack of tongzhi/LGBTQ+ basic health statistics and studies was noted in 2004 by Taiwan Women’s Health, again in 2011 by Taipei City Government’s Tongzhi Friendly Medical Guide, and yet again in 2021 by an updated version of this guide. Likewise, the lack of comprehensive tongzhi/LGBTQ+-friendly medical indices and standards is another problem yet to be addressed. This inconsideration is a direct result of the aforementioned cis-heteronormative assumptions. An obvious example is when medical intake forms only allow for a binary sex check box, which leaves out nonbinary people, intersex people, and transgender people who have not yet or are unable to change their gender. A subtler example is that lesbians’ risk of sexually transmitted diseases is underestimated (such as the high prevalence of bacterial vaginosis due to an overemphasis on gay men/MSM (men who have sex with men) and HIV.
Most studies and public health programs on tongzhi/LGBTQ+ health are about gay men/MSM and HIV, so much so that this topic has become almost synonymous with tongzhi/LGBTQ+ health (同志健康). An illustrative example is Liu a study titled “Domestic tongzhi/LGBTQ+ health behaviour research and tongzhi/LGBTQ+ health community service progress” (我國同志健康行為調查與同志健康社區服務中心推動成果), and yet it is solely about HIV issues of gay men and MSM. Another common theme in tongzhi/LGBTQ+ health is mental health problems and related issues, including suicide, intimate partner violence (IPV), and family rejection after coming out, which inadvertently paints a picture that tongzhi/LGBTQ+ are always sadder, angrier, and living on the verge of abnormality.
However, there is so much more to tongzhi/LGBTQ+ health. For instance, in the U.S., Health Professionals Advancing LGBTQ Equality (previously known as the Gay & Lesbian Medical Association) published a widely circulated “Top 10 Things Lesbians Should discuss with Their Healthcare Provider” (2012), which highlights crucial topics for exploration, such as how lesbians might have higher risk factors for breast cancer but are less likely to get screenings. In the U.K., the NHS conducted a nationally representative study on the health of lesbian, gay, and bisexual adults in 2021 and found that 27% of LGB adults were current smokers compared to their heterosexual counterparts at 18%, with lesbian and bisexual women reaching 31%. While some findings are common in different countries, it is essential to pay attention to cultural differences and local conditions. Obesity, for example, is a prevalent problem among lesbians in the U.S and the U.K. and has not been observed in Taiwan.
A few Taiwan studies about tongzhi/LGBTQ+ health are situated outside the two most common themes discussed above. For example, Leung and Huang studied the prevalence of findom (condom for fingers) among WSW (Women Who Have Sex with Women) in Taiwan and found only 18.9% of 397 surveyed had used findom in the previous year; Tian and Shen explored the experiences of lesbian pregnant women, and reported how they encounter heterosexual assumptions, including having to fill out the father’s name on the medical forms*; and Leung (2014) found that 89.1% lesbian/bisexual women in Taiwan had never had a Pap smear, compared to 54.9% heterosexual women.
Despite these exceptions, there is still a wide gap in research and government routine data collection about tongzhi/LGBTQ+ health issues. Therefore, tackling tongzhi/LGBTQ+ health disparity requires an intersectional approach. Intersectionality is a frame to understand the “ways in which systems of inequality based on gender, race, ethnicity, sexual orientation, gender identity, disability, class, and other forms of discrimination ‘intersect’ to create unique dynamics and effects”.
Take the intersection of being Indigenous and gay as an example. As indigenous tribes are usually smaller and more tight-knit, the pressure to remain in the closet is often stronger than for the Han people. Meanwhile, an Indigenous tongzhi/LGBTQ+ might need to hide their indigenous identity from the Han majority to not “falsely represent one’s tribe.” The founder of an Indigenous tongzhi group 彩虹同心原, Liu Wen-Hsien (劉文賢), described how his friend from the same tribe avoided walking with him at a pride parade because Liu was wearing the traditional tribal clothes. He also recalled his post on an indigenous online forum to invite Indigenous tongzhi/LGBTQ+ to join the pride parade was removed because “tongzhi issues do not belong to an indigenous forum; it should be posted in a tongzhi forum”. Without the intersectional perspective, Liu is forced to be either gay or Indigenous when these two are integral to his identity. Along the same lines, socioeconomic status, ableness, and location of residence, among many other categories, create endless possible social positionings in which people experience health and ill health differently. For example, low SES lesbian couples in Taiwan who wish to become pregnant through assisted reproductive technology (ART) face double exclusion: they are excluded by law from accessing ART in Taiwan. Furthermore, they cannot afford to travel to a different country for the procedure.
New framings are also desperately needed. HIV and its comorbidity (the simultaneous presence of two or more diseases or medical conditions in a patient) are not the only health issues for gay and bisexual men; they have other health needs, and other people can get HIV too. This simple notion seems to escape the public’s imagination of disease and sometimes clouds the professionals’ judgment. Similarly, the stress of coming out has been overwhelmingly linked to a plethora of adverse mental health outcomes, but from a resilience perspective, having to navigate coming out might increase one’s resilience and competence in reconciliation. and in turn, bring positive health outcomes to tongzhi/LGBTQ+. Scholars have warned against pathologizing queerness in studying queer health needs.
Recently, a trend has emerged in tongzhi/LGBTQ+ health studies concerning long-term care issues for senior tongzhi/LGBTQ+, and, responding to the caveat not to pathologize queerness, this topic does not have to be sad stories of lonely older tongzhi/LGBTQ+ having no family to care for them. Instead, this issue could bring back discussion on diverse families. For example, can a group of tongzhi/LGBTQ+ not related by blood or marriage choose to live together and form a family? This question once stirred up extreme controversy in Taiwan because some opponents accused “multiple people family” as a way for tongzhi/LGBTQ+ to legalize orgy, just as they argued that legalization of same-sex marriage would ruin our society. Therefore, it might be time to revisit the possibility of chosen family and recognize how a strong family contributes to health.
The possibilities to study tongzhi/LGBTQ+ health are endless. Tongzhi/LGBTQ+ issues are a chance to reexamine existing power structures, assumptions, beliefs, and biases and challenge exclusive and even oppressive systems. As Taiwan has pledged to adhere to international human rights standards and aspires to be the leader in tongzhi/LGBTQs rights in Asia, we cannot afford to ignore tongzhi/LGBTQ+ (nor anyone else) in health, medicine, and social policies.
* Data from Tian and Shen (2019) was likely collected before same-sex marriage was legalized, so that the situation might be different now.
JhuCin Rita Jhang, Ph.D is a Project Assistant Professor in the Global Health Program, National Taiwan University
This article was published as part of a special issue on healthcare in Taiwan.