Sexualized drug use (SDU) involves using drugs to enhance sexual activity with chemsex or party and play being prevalent among gay and bisexual men and men who have sex with men. This practice is linked to significant health risks, including mental health problems and HIV/STI transmission. Despite extensive research, traditional public health approaches often focus on the pathological aspects of SDU, ignoring broader social and cultural contexts. Particularly for harm reduction, lived experiences and personal strategies practiced by people who use drugs also tend to be excluded from intervention conceptualization. This dissertation addresses these gaps by adopting a counterpublic health (CPH) perspective, focusing on the health of sexual and gender diverse (SGD) people. This research is presented in three papers. Paper 1 is a narrative review of CPH literature focused on subaltern counterpublics, defining its tenets and identifying contexts where CPH is relevant. This review highlights the need for inclusive, context-sensitive public health approaches, proposing an emergent framework to enhance the understanding and application of CPH principles. Paper 2 critiques the assumption that all individuals conform to mainstream public health discourses, using harm reduction to explore how SGD individuals engaging in SDU navigate HIV/STI prevention and drug use risk reduction strategies. Through interviews with users of sexual networking apps, it captures their experiences, informing more nuanced harm reduction interventions. Paper 3 examines the interplay of moral agency, empathy, and stigma among SGD individuals in SDU contexts within a CPH framework. It investigates how participants perceive and exercise moral action and empathy while navigating stigma, emphasizing collective responsibility and inclusivity in harm reduction strategies. This dissertation advocates for reimagining public health through CPH, promoting inclusive and contextually-aware health interventions. By centering marginalized voices and valuing local knowledge, it aims to improve health outcomes and reduce disparities among marginalized communities.

Background

LGBTQ+ people experience significant barriers in accessing health care including inadequate provider knowledge and stigma in health care settings. Undergraduate medical education programs have increased efforts to integrate LGBTQ+ health topics, such as comprehensive sexual history taking and gender-affirming practices, into their curriculums to provide clinically inclusive care for LGBTQ+ patients.

Approach

A Topic Steward was appointed to oversee the integration of LGBTQ+ health topics throughout the existing undergraduate medical curriculum. The aim was to expand the LGBTQ+ health curriculum for undergraduate medical students through teaching comprehensive sexual history taking; offering specialty-specific LGBTQ+ health education through clerkships; describing the difference between sex assigned at birth, gender identity, and gender expression; describing the difference between sexual orientation and sexual behaviour; identifying health care disparities that LGBTQ+ people experience; and developing an inclusive approach to providing medical care for LGBTQ+ patients.

Evaluation

The program started in July 2017 with UCSFSOM students in their first, second, or third years (~150 medical students per year) participating in the integrated curriculum that included didactic lectures, small group discussions, and LGBTQ+ clerkship opportunities. The hours of LGBTQ+ health curriculum at the UCSFSOM increased from 4.5 hours to 15–20 hours in approximately 2 years under the Topic Steward approach.

Implications

The next step is to develop standardised tools for assessing LGBTQ+ health competencies for medical students. This involves integrating more questions regarding LGBTQ+ health topics in traditional exams at UCSFSOM and developing specialty-specific assessment instruments that other medical schools could administer to test core competencies in LGBTQ+ health.