600236

research-article2015
HPQ0010.1177/1359105315600236Journal of Health PsychologyGraham et al.

Article

Journal of Health Psychology

The importance of health(ism):

2017, Vol. 22(2) 237­–247
© The Author(s) 2015
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DOI: 10.1177/1359105315600236
gay, bisexual, pansexual, queer journals.sagepub.com/home/hpq

and transgender individuals’

understandings of health

Katie Graham, Gareth J Treharne, Christian Ruzibiza

and Max Nicolson

Abstract
This study investigated understandings of health among lesbian, gay, bisexual, pansexual, queer and/
or transgender people, who are under-represented in research. The study involved 12 focus groups in
Aotearoa/New Zealand with 47 participants who identified as lesbian, gay, bisexual, pansexual, queer and/or
transgender and responded to an advert inviting participants without chronic illnesses. Three themes were
inductively formulated: health is important because education and protection efforts are seen as required
to preserve health, health is seen as holistic, and contextual factors are seen as creating health risks. These
findings provide insights into how lesbian, gay, bisexual, pansexual, queer and/or transgender people’s
understandings of health draw upon notions of healthism.

Keywords
arthritis, focus groups, gender identity, healthism, HIV/AIDS, qualitative methods, sexual orientation

The understandings of health held by lesbian, gay,
bisexual, pansexual, queer and/or transgender
(LGBPQT) individuals have received relatively
little attention in qualitative research compared to
the broad and often implicit focus on heterosexual
individuals (Braun, 2008; Crawford, 1994, 2006;
Crossley, 2003; Treharne, 2011). Past research has
tended to treat LGBPQT people’s health as
entirely centred around reducing HIV risk or liv-
ing with HIV/AIDS (see Jowett and Peel, 2009;
Lawton, 2003; Treharne, 2011). It is important to
explore understandings of health among margin-
alised groups such as LGBPQT people to give
voice to explanations for health and views on
moral arguments around health and risk.
People’s understandings of the nature and
importance of health can be theorised as socially
constructed (Crawford, 2006). The ability to define
oneself as ‘healthy’ is in part in reaction to being
able to label others as ‘unhealthy’, particularly in
relation to morally loaded conditions such as HIV
(Crawford, 1994). Hughner and Kleine (2004)
compiled and reviewed worldwide research on
University of Otago, Aotearoa/New Zealand
Corresponding author:
Katie Graham, Department of Psychology, University
of Otago, PO Box 56, Dunedin 9054, Aotearoa/New
Zealand.
Email: kejgraham27@gmail.com
238 Journal of Health Psychology 22(2)
people’s views of ‘health’. They discovered 18
themes across conceptualisations of health, which
included health as absence of illness, the ability to
carry out daily chores, inconsistency between
health beliefs and behaviours, ideas about the
value placed on health and the moral obligation to
maintain health. Religious beliefs in an afterlife no
longer dominate understandings of health; instead,
the goal of attaining longer life motivates people to
constantly be seeking ‘good’ health (Crawford,
2006). Policies to protect personal health have
increasingly being written into laws and embedded
within a culture of ‘healthism’ (Crawford, 1980,
2006).
Crawford defines healthism as a cultural
belief system in which an individual’s health is
highly valued. Health in this context is viewed
as holistic so healthism emphasises individual
actions and personal behaviour to actively seek
good health. Time, energy and money all play a
part in individuals maintaining their good
health and therefore their good life (Crawford,
1980). In locations where healthism is a domi-
nant view, health promotion that acknowledges
this individual view of health may be more suc-
cessful. This approach can be seen in New
Zealand health initiatives like safe sex promo-
tion that encourages the pursuit of good health
through individual responsibility for safe sex
(Braun, 2008).
While a culture of healthism positively
encourages the pursuit of good health through
the social construction of its importance, it also
has the potential for negative consequences.
Overemphasis on health can result in people
being so focused on performing all the impor-
tant health behaviours that they do not have a
chance to enjoy life (Evans, 1988, cited in
Marks et al., 2015). Health promotion con-
structs the healthy and moral individual, exclud-
ing others and casting them as unhealthy
(Gurrieri et al., 2013; Stephens, 2008). The cul-
ture surrounding healthism can also produce
opportunities for inclusion and exclusion of
marginalised groups.For example,second-
generation immigrants to countries where heal-
thism is a dominant view have been found to
take up healthism as a means to fit in or
continue their outsider status by maintaining
their alternative health beliefs (Barker-Ruchti
et al., 2013). Healthism may also overlook soci-
etal factors that can cause health inequality and
encourage social and self-blame for poor health
or illness (Cheek, 2008; Crawford, 1994, 2006).
Despite this widespread value placed on health,
understandings of what health is vary greatly.
This study aimed to explore LGBPQT people’s
understandings of health in particular.
Social understandings of a link between
health and morality mean that being healthy
defines not just wellness but also impacts moral
identity. Crossley (2003) conducted four focus
groups to explore people’s attitudes towards
health and the medical system. Participants of
various ages and employment circumstances
understood a person’s behaviour as the biggest
factor in distinguishing between being healthy
and unhealthy. The notion that behaviours can
affect health is commonly used in health pro-
motion in an attempt to stop individuals acting
in certain ways that may diminish their future
health. The success of this health promotion
relies on the assumption that everybody has a
shared understanding of what health is, values
their health and therefore wants to maintain it
(Marks et al., 2015). The effectiveness of reduc-
ing unhealthy behaviour, through health promo-
tion, has been questioned, particularly in
relation to social contextualisation (Stephens,
2008).
Age, gender and sexual orientation are three
social contextualising identity characteristics
that can shape an individual’s understandings of
health. Age contextualises understandings of
health because as people age, some illnesses are
seen as normal or inevitable (Lawton, 2003),
particularly arthritis (McGavock and Treharne,
2011). Gender can also play a direct part in
health, given that some illnesses only affect
women or men (Stephens, 2008). Transgender
individuals who consider gender affirmation
surgeries can also have specific health concerns
(Riggs et al., 2015). Health and illness also
relate to the ability to successfully enact one’s
gender role. Women and men take part in gen-
dered health-related behaviours not only in
Graham et al. 239
pursuit of health but also as a way of ‘being’
their female or male identity (Lyons, 2009).
Sexual orientation is another contextualising
identity characteristic that can affect many
aspects of life, including health, in both direct
and indirect ways (Bjorkman and Malterud,
2009; Stevens and Hall, 1988; Treharne, 2011).
Adams et al. (2013) found the gay men in
Aotearoa/New Zealand focus on individual
responsibility in their explanations of health but
noted that greater societal acceptance of gay
men was also seen as important for improving
health. LGBPQT individuals may have to deal
with negative attitudes of health professionals if
their sexual orientation is disclosed or requested
(Adams et al., 2013; Bjorkman and Malterud,
2009; Stevens and Hall, 1988).
Lesbian women seem to have a specific con-
texualised understanding of their personal risk
of sexually transmitted infections (STIs), par-
ticularly HIV that contrast with established
ideas about gay men and bisexual/pansexual
people being at risk. Dolan and Davis (2003)
found that some lesbian women feel protected
from HIV and STIs due to their community,
social circles and women being trustworthy;
others took a contrary position based on per-
sonal experience of an STI. Bjorkman and
Malterud (2009) suggest that this notion of
women having a low risk of acquiring a STI
during sex with a woman extends to health pro-
fessionals, which shapes the information given
to LGBPQT individuals.
Very little research has addressed the experi-
ences of LGBPQT individuals with chronic ill-
nesses other than HIV/AIDS. Jowett and Peel
(2009) used an online survey to gather qualita-
tive data about lesbian, gay and bisexual (LGB)
participants’ experiences of chronic illnesses
more broadly. Participants reported isolation
from LGB communities due to illness and they
experienced assumptions of heterosexuality
within healthcare support and information pro-
vided. Jowett and Peel (2009) also found that
overt homophobia exists within healthcare.
Some participants with chronic illnesses who
required home help even had to deal with hom-
ophobic remarks within their own home. Little
is also known about the overall understandings
of health held by LGBPQT individuals without
a chronic illness. This study builds on existing
qualitative research by enquiring about what
health means to currently ‘healthy’ LGBPQT
people, particularly in relation to homophobia
and heteronormativity.
Geographical location can also affect views
of health and access to adequate and affordable
healthcare. This study was conducted in New
Zealand which has a partially funded public
health system (New Zealand Ministry of Health,
2013). Within this system, most hospital visits,
operations and emergency care are fully funded
by the government. Doctors visits are charged,
but certain populations are provided govern-
ment subsidies, many prescription medications
are also partially subsidised. LGBPQT individ-
uals within New Zealand are likely to be influ-
enced by general health system policies like
these but also polices specifically aimed at
LGBPQT communities.
A review of worldwide health policy for les-
bian, gay, bisexual and transgender (LGBT)
individuals by Adams et al. (2010) suggested
that few policies directly target the health of
this group. The review included worldwide
research and several policy documents from
New Zealand. Overall assessment of these sug-
gests that in line with a culture of healthism,
many documents focus on individual responsi-
bility for health. Adams et al.’s (2010) review
also identified that voices of LGBT individuals
or communities were often absent from research
and policy documents. Those polices targeting
LGBT individuals within New Zealand often
focus on safe sex promotion for gay men (New
Zealand Ministry of Health, 2003). This area is
seen as being relevant and important by
gay men for their health (Adams and Neville,
2012), but the health needs of LGBT individu-
als are broader than this. Research shows over-
representation of LGBT individuals in statistics
on mental health problems but few policies or
providers that cater to the unique needs of this
group (Adams et al., 2012).
The aim of this study was to investigate the
understandings of health among LGBPQT
240 Journal of Health Psychology 22(2)
individuals who, as yet, had no chronic illness.
In order to stimulate focus group discussions
about health and illness, participants were asked
about their beliefs concerning HIV/AIDS and
rheumatoid arthritis as two examples of chronic
illness. HIV is a virus which compromises the
immune system and can eventually progress to
AIDS (Trapence et al., 2012). The three main
sources of transmission of HIV are sexual, peri-
natal and parenteral (Trapence et al., 2012). The
infectious nature of HIV has seen it spreading
to a pandemic level but still with perceived con-
nections to sexual orientation (Trapence et al.,
2012). Rheumatoid arthritis is an autoimmune
illness that causes inflammation and potential
erosion of the joints, which affects around 0.5–
1 per cent of the population. While rheumatoid
arthritis can occur at any age, it is most com-
mon in those older than 40 years (Scott et al.,
2010). The aim of raising these two specific
example illnesses was to expand the discussion
beyond HIV/AIDS while also acknowledging
its ongoing connection to sexual orientation.
This study qualitatively explored LGBPQT
individuals’ views of health and illness to
address the following questions:
1. How do LGBPQT individuals talk about
‘health’ and what understandings do
they hold about health?
2. What sources of information do
LGBPQT individuals draw on in their
understandings of health?
3. Do different groups of LGBPQT people
have different understandings of health
and how might these impact their will-
ingness to seek health information or
access healthcare?
Method
Design
This study involved a focused inductive the-
matic analysis of qualitative data (Braun and
Clarke, 2006). Data were collected through
semi-structured focus groups for a larger study.
Focus groups are a good way to research topics
related to social understandings. They allow
group agreement and disagreement, which can
highlight different positions on dominant views.
They also allow researchers to ask follow-up
questions which can mean things can be under-
stood more thoroughly and important points can
be expanded on (Frith, 2000). The focus groups
were audiorecorded with the approval of partici-
pants. The study was granted ethical approval
from the University of Otago Department of
Psychology.
Participants
There were a total of 47 participants, of whom
27 identified as women, 17 as men, 2 as gender
fluid and 1 as transgender; 11 self-identified as
lesbian (or ‘woman who likes women’), 16 as
gay, 13 as bisexual, 5 as pansexual and 2 as
queer. There were 12 different focus groups: 7
groups contained people of a single gender (the
original study design) and the other 5 groups
contained people with multiple gender identi-
ties (at the instigation of participants). The
focus groups were attended by up to five par-
ticipants and lasted 44–118 minutes. Participants
were aged 18–71 (median 22) years. Two les-
bian women aged 71 years took part in one
group; although they are notably older than
other participants (the next oldest being
32 years), their data contributed to a lively and
relevant discussion. Four researchers facilitated
the groups: one identifies as a lesbian woman
and three as gay men. The researchers shared
these identities with participants at the start of
each group.
Procedure
Participants were recruited through purpose-
ful sampling of individuals who identify as
LGB, transgender or queer (as a reclaimed
term). Posters advertising the study were
placed around a university campus and rele-
vant local email lists and social media groups
were contacted. Snowball sampling also took
place with participants recommending the
study to others.
Graham et al. 241
Most participants were directly emailed an
information sheet and the list of discussion top-
ics prior to their focus group; other participants
attended with a friend who had received the
information sheet and list of topics. On arrival
to the focus group session, participants were
asked to fill out a consent form that reiterated
the main points of the information sheet and
then completed a demographicquestionaire .
They were informed of general procedure for
the focus group and their right to leave at any
time. Participants were given a NZ$15 grocery
voucher as compensation for any expenses
related to participation in the research.
Data analysis
The audiorecordings from the focus groups
were transcribed by a professional transcriber.
Identifying details such as names and places
were removed to protect anonymity. Participants
were contacted at this point and again given the
option of viewing, changing or clarifying any-
thing they had said, but none took up this offer.
The data were coded for information about
the specific research questions stated in the intro-
duction. Data were analysed inductively from a
contextualist point of view (Braun and Clarke,
2006). Participants’ statements were interpreted
with the idea that individual experiences and sit-
uations produce individual meaning, but larger
societal and cultural norms influence these
meanings (Braun and Clarke, 2006).
The data were primarily coded by the first
author who became familiar with the data by
listening to the audiorecordings to check the
accuracy of the transcripts and then systemati-
cally reading the transcripts to generate initial
codes. Preliminary themes were created by
combining codes across the first six focus
groups. At this point, the themes were checked
and reworked to ensure that they were an accu-
rate reflection of the data extracts within them
and the initial data set. Thiswas written up as an
undergraduate dissertation (by the first author
(K.G.) under the supervision of the second
author (G.J.T.). The initial analytic steps were
then repeated in two ways after further focus
groups were conducted. Data extracts were dis-
cussed by all authors by email and in a series of
meetings. The initial thematic structure was
updated and the themes and subthemes were
named to summarise their content (Braun and
Clarke, 2006).
Finally, specific participant quotes were cho-
sen to illustrate the main themes and subthemes.
These quotes are presented in the ‘Results’ sec-
tion. Notes about anonymised information and
other clarifications are contained in square brack-
ets (e.g. [city]) and in some places quotes have
been condensed; missing portions are indicated
within square brackets containing three dots.
Results
Theme 1: health is important
(to everyone)
The way LGBPQT participants spoke about their
understandings of health indicated that it is a prior-
ity in their lives and should be a priority for every-
one. This theme came across in two different
subthemes. Subtheme 1.1 is about the ways par-
ticipants described a universal need for health edu-
cation and subtheme 1.2 is about the actions that
participants recommended for health protection.
Subtheme 1.1: health education signifies that health
is important.  Participants emphasised the need
for health education for themselves and others,
which contributed to their construction of the
importance of health. In all of the focus groups,
participants talked about the reasons why they
felt people should be educated about things that
put their health at risk, and many participants
raised concern over their own lack of health
knowledge:
Um I dunno, just probably the main focus being
educating people coz I can safely say I feel
uneducated on both topics. (Group 3, participant
1: lesbian woman; in regard to HIV/AIDS and
rheumatoid arthritis)
Within this emphasis on a need for health
education, there was specific concern over the
lack of sex education for same-sex couples:
242 Journal of Health Psychology 22(2)
P4: I didn’t even know what a dental dam is until
I looked it up.
P3: I didn’t even know what one was until I came
to uni (laughter) so.
(Group 11, participant 4: bisexual/pansexual
woman then participant 3: woman who likes
women)
This lack of personally relevant sex educa-
tion for participants indicated a gap in the uni-
versality of health education, which they used
to further demonstrate that health education is
important to them.
Subtheme 1.2: health protection signifies that
health is important. The second subtheme that
indicated the broad importance of health to par-
ticipants was health protection. This subtheme
was present in the way participants spoke of
both the need for personal protection to main-
tain their health and also the responsibility to
protect others if participants themselves were
inflicted with a transmittable illness:
that would be such a terrifying thing to, to pass it
on without knowing. (Group 9, participant 5:
bisexual woman)
In many groups, there was discussion about
men who willingly seek to contract HIV
(referred to as bug-chasers). The discussions
focused on refuting the complex logic of bug-
chasing which was given two explanations:
(1) as being a means to reduce anxiety over
the fear of contracting HIV or (2) as a way of
gaining a sense of identity within the gay
community. This talk indicated that partici-
pants thought health was something to be pro-
tected as they found it hard to understand why
someone might be willing to purposely seek
out illness:
Umm, it sounds kind of ridiculous really, I don’t
understand why you’d do that to yourself […] just
actively seeking a way to do something really
harmful for themselves. (Group 10, participant 1:
bisexual transwomen)
Theme 2: health is holistic
(if you get ill)
The second theme that came across in partici-
pants’ talk was that health is, or should be seen
as, holistic. This conceptualisation was evident
in the ways participants discussed what it might
be like to live with a chronic illness like HIV/
AIDS or rheumatoid arthritis. The holistic
nature of health was highlighted in the way par-
ticipants talked about how illnesses affect
health in ways that start with the physical body
but soon surpass the physical body. This pattern
was evident for both rheumatoid arthritis and
HIV/AIDS:
Yeah the whole physical aspect of [arthritis], like
losing your ability to do certain things, like
become helpless almost. (Group 7, participant 2:
bisexual woman)
some people might not want to engage in a
relationship with somebody with a long term
debilitating disease […] so with like um
rheumatoid arthritis, they might end up in a
wheelchair and somebody might not be willing for
that commitment. (Group 9, participant 2: bisexual
woman)
not only just your physical body being
compromised but also the stigma attached to
AIDS. (Group 8, participant 4: queer woman)
It’s probably the loneliness issue of going on with
HIV, I’d be frustrated with society not accepting
me. (Group 2, participant 2: gay man)
Participants hypothesised that social isola-
tion is paired with a reciprocal impact on emo-
tional health. Professional psychological support
such as counselling was raised in a way that sug-
gested it would be available for all patients and
would be particularly needed by people with
HIV/AIDS because of the likely terminal nature
of the condition:
R1: So what other kinds of support do you think
people with HIV get?
P3: Counselling.
Graham et al. 243
R1: Why would they need the counselling do
you think?
P3: 
Um that fact that you’ve gotten this
debilitating disease which could eventually
kill you or shorten your life dramatically
that um and people’s reaction to you and
social isolation once again.
(Group 5, researcher 1 then participant 3: gay
man)
Both the physical symptoms of the illness
and society’s reactions to the illness were cited
as reasons emotional health might be dimin-
ished, demonstrating how participants held a
model of health as holistic.
Theme 3: contextualising risk
Participants talk often centred on ideas about
risk. This talk suggested that participants viewed
factors including geographical location, age and
sexual orientation as having the ability to affect
actual and perceived risk. These ideas about risk
were presented in a way that cast illnesses like
HIV and rheumatoid arthritis as things that hap-
pened to others:
Umm no I don’t think me or anyone here is really
like that in-risk of getting AIDS or HIV […] like
this is [city], you know, New Zealand (laughter).
(Group 5, participant 1: gay man)
Age was also a factor that participants used
as an indicator of risk and a way to remove it
from themselves:
R1:  Mmm so have you had a Pap smear?
P2:  No I haven’t.
R1:  Would you ever?
P2: Yeah I think it’s important to but it just
hasn’t crossed my mind, I think I just think
that I’m young and therefore bulletproof,
I’m like ah it’s an old lady thing or I don’t
know anything about it so yeah.
(Group 1, researcher 1 then participant 2:
bisexual/pansexual woman)
Sexual orientation was presented as a con-
textual factor that affected risk perceptions.
These perceptions came from both the partici-
pants’ own ideas and also through the actions of
healthcare professions:
they’ve said ‘Do you want any condoms?’ and I’ll
go ‘No thank you, I’m in a gay relationship,’ and
they go ‘Oh, very good’. (Group 9, participant 5:
bisexual woman)
They do the testing on campus sometimes but
whenever I go up there and I wanna get tested just
for fun, […] I feel like […], I don’t have a right to
get tested because it’s typically you know, caught
not by lesbians. (Group 11, participant 3: woman
who likes women)
Discussion
In this study, we found that LGBPQT partici-
pants viewed health as important, holistic and
contexualised. The importance of health came
across in the way participants’ talk emphasised
protection of health and recommended accessi-
ble health education to inform protection.
Participants held holistic views on health but
mainly because people with a chronic illness
are seen as losing physical, mental and social
well-being. Contextual factors like geographi-
cal location, age and sexual orientation were
described as influencing the risk of getting ill.
Participants framed risk in a way that removed
themselves from being implicated as at risk.
These findings expand previous research on
understandings of health and have implications
for health promotion, as discussed below.
The three themes in this study all indicate
that LGBPQT individuals understand health in
a way that draws on a broad culture of health-
ism. This aligns strongly with Crawford’s
(1980, 2006) idea of health being socially con-
structed as important and staying healthy as a
moral way of acting. These themes also fit with
Crossley’s (2003) findings that people feel
244 Journal of Health Psychology 22(2)
morally obliged to maintain their health through
personal behaviours. The ideas about health
drawn upon by the participant within our study
show that this culture of healthism focuses
strongly on personal responsibility in maintain-
ing health and preventing illness. Participants
suggested education as a way to encourage this.
In previous research with gay men in the United
States (Siconolfi et al., 2014) and New Zealand
(Adams et al., 2013), similar views suggesting
personal responsibility and actions as key to
staying HIV negative have been expressed.
The source of these health beliefs is likely
broad. Research suggests contributions of gov-
ernment and schooling which eventually leads
to individuals internalising and maintaining
health-preserving behaviours and ideas (Ayo,
2012; Burrows and Wright, 2004).
In line with the notion of healthism, partici-
pants also viewed health as holistic, in that ill-
ness was seen as affecting physical, psychological
and social areas of life. Ward et al.’s (2011) par-
ticipants who had rheumatoid arthritis viewed
their illness in the same way, talking of the physi-
cal, psychological and social impacts. A holistic
view of health has been incorporated into the
treatment of illness. Using aspects of spirituality
has been shown to be effective in improving the
lives of people with rheumatoid arthritis and sug-
gested as being promising for the impacts of
other illnesses like HIV (Vance et al., 2008). The
holistic nature of health has also been proposed
as being an effective target for health promotion
especially for LGBPQT individuals. Cahill et al.
(2013) suggested a need for community-level
health promotion that targets social understand-
ings surrounding sexual orientation. They sug-
gest that views held by society affect the
psychological health of LGBPQT individuals
making them more susceptible to poor health.
Adams et al. (2013) also found that gay men
believe that changing social ideas about sexual
orientation could help improve their health.
As in previous studies, being LGBPQT con-
textualised understandings of health.
Participants used their location and identity as
New Zealanders and the taken-for-granted
access to the New Zealand health system as a
way to remove themselves from the risk of dis-
eases like HIV. This finding links closely to the
national identity explanations drawn upon by
Braun’s (2008) sample of mainly heterosexual
New Zealanders. Braun’s participants mini-
mised their own risks of contracting STIs like
chlamydia, citing other New Zealand cities as
where the high STI rates were. Within this
study, participants acknowledged that serious
illness is possible but in a way that emphasised
HIV as something that is seen as only happen-
ing in other places within Aotearoa/New
Zealand or around the world.
Age was also a factor used by participants to
contextualise their distance from health risks
particularly in relation to rheumatoid arthritis.
Participants had little information about this ill-
ness and often associated it with elderly people
unlike themselves. McGavock and Treharne’s
(2011) participants held similar ideas about
rheumatoid arthritis, citing knowing little about
the illness and linking it primarily to older
people.
Sexual orientation or identity appeared to be
used by participants as a way to assess their sex-
ual health risks. Like the findings of Dolan and
Davis (2003), lesbian women within this study
often considered themselves at very low risk of
STIs. Participants suggested that this perception
was also held by some health professionals in
concordance with the views of Bjorkman and
Malterud’s (2009) Norwegian lesbian partici-
pants. The beliefs held by both lesbian women
and health professionals could be playing a part
in statistics, suggesting lesbian women access
health services and screening less often than het-
erosexual women (e.g. McNair, 2003).
Overall, participants’ assessment of their
own risk was often described in relation to other
groups. They used characteristics unlike the
ones they identified in themselves to remove
themselves from the threat of ill health. This
removal of risk is the same as that suggested by
Flowers and Langdridge (2007). They describe
the way HIV is cast as a gay disease by Crossley
(2002), therefore removing the risk from heter-
osexuals. Gurrieri et al. (2013) suggest that
health promotion uses a similar technique that
Graham et al. 245
creates a clear divide between healthy and
unhealthy.Participants regularly used contex-
tual factors to remove themselves from health
risks. Previous research shows positive and
negative aspects of a culture of healthism and
the associated health promotion messages
(Cheek, 2008; Crawford, 1994, 2006; Gurrieri
et al., 2013). Future health promotion research
may benefit from critical evaluation of what is
said as well as what is not said in health promo-
tion messages, along with considering the evi-
dence it is based on (Carter et al., 2011;
Stephens, 2008). These messages can affect
views of personal risk and understandings of
health, as is highlighted by our participants in
this study.
The aim of this research was to investigate
LGBPQT people’s understandings of health.
Our approach to thematic analysis involved a
contextualistic interpretation of what LGBPQT
participants discussed. Attempts were made to
receive feedback with participants contacted
throughout the research process, but none took
up the offer, which is a limitation regarding
confirmability of the findings (see Treharne and
Riggs, 2014). Another limitation of this study is
the self-selection of participants. There may be
different qualities between those LGBPQT
individuals willing to take part in a focus group
study and those not. Posters advertising the
study specified LGBT participants. This was
done with the aim of including participants who
may be commonly overlooked or unidentified
in research. Treharne (2011) suggested that
while attempting to be inclusive in recruitment
of people with diverse sexual orientations,
exclusion can also occur. While our posters
attempted to include individuals, we did not list
every possible sexuality and gender. We had
some participants identify as sexualities and
genders other than those listed, but it still may
have restricted the range of people willing to
take part. Our range of participants is diverse,
but self-selection and selective recruitment may
have limited the range of LGBT individuals’
experiences included within these findings.
The researchers who conducted this research
would be what LaSala (2003) calls ‘insiders’.
This means that we identified as members of
the LGBPQT group we were studying and
revealed this to all participants. LaSala (2003)
suggests that insider status may allow for better
trust, encouraging participants to share more.
At the same time, insider status may cause
researchers to not question unspoken assump-
tions due to shared understanding. Hayfield and
Huxley (2015) suggest that aspects of insider
and outsider perspectives are present in all situ-
ations, particularly in relation to sexual orienta-
tion. The diverse nature of people means while
we may act as insiders on some aspects, we are
outsiders on others. Due to the relatively diverse
nature of both our participants and research
team, it is likely we managed to take advantage
of some aspects of both the insider and outsider
perspectives.
Given the emphasis on the lack of relevant
sexual health education for LGBPQT within this
study, future research could benefit from explor-
ing this area further. Exploring the sources of
information about sexual orientation for sexual
health teachers and the way they portray these
ideas to their student would be of interest. This
study indicates that little is included that relates
to same-sex couples according to our partici-
pants in thinking back to being at school. What
is included may often be assumptive about
LGBPQT people. Future research could explore
where teachers get their information from and
views of their teaching. This could provide a
better understanding of whether teachers are
aware of their oversights, aware of the way they
portray sexuality to their students and identify if
teachers have access to relevant and helpful
sources to inform their teaching.
Conclusion
LGBPQT individuals within this study viewed
health in ways similar to that found by previous
studies of both LGBT and heterosexual partici-
pants. Like in previous research, participants
placed importance on their health and wanted
education regarding ways to protect it that draws
on notions of healthism (Crawford, 2006;
Hughner and Kleine, 2004). Participants also
246 Journal of Health Psychology 22(2)
held holistic views about the impacts of illness.
The identities of LGBPQT participants were
seen as affecting personal risk perceptions.
Their various identities were used as a way to
frame their risks. Overall, this study gave insight
into the priority LGBPQT New Zealanders
place on their health. Developing health promo-
tion that is relevant and accessible for this popu-
lation is important to them and could be a goal
for New Zealand health promotion.
Acknowledgements
We thank the participants who took part in this
research.
Declaration of conflicting interests
The author(s) declared no potential conflicts of inter-
est with respect to the research, authorship, and/or
publication of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
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