‘It’s Important to Do What We Can’.

Julia Raifman Assistant Professor of Health Law, Policy & Management

Breakfast: Cinnamon Puffins cereal

Hometown: Rochester, Minnesota (“It makes the Boston winter seem warm.”)

Extracurricular: Hiking (“My husband and my dog and I do a lot of hiking. This fall we got to go explore the fall foliage for the first time in New Hampshire in places like Hedgehog Mountain. Minnesota is very flat, so mountains are especially exciting to me.”)

Watch the video above for a preview of Raifman’s Think. Teach. Do. presentation.  Read her “In Conversation With” below  to learn more about her research here at SPH.  Register today for Think. Teach. Do. Miami.

You joined SPH faculty in fall 2017. What led you here?

I really appreciate the social justice mission of SPH. It’s a great place to be working on research on how policies and institutions shape health inequities. I also came here because when I interviewed, the students were remarkably happy, and that was a wonderful reflection of an institution that values everybody who’s here.

What led you to studying how policies shape LGBT health?

When I initially worked on HIV globally, I was reading about HIV among men who have sex with men (MSM) and was curious about the HIV rate among MSM in the US. I knew that it was about half a percent in the general US population, and I figured it must be higher among MSM—“Probably 1.5 percent or something really high like that,” I thought.

When I looked it up, it was 18 percent. I thought it was a typo, that it was missing a decimal point. It was not. That’s actually the proportion of MSM in the US who have HIV. MSM in the US have 80 times the lifetime risk of HIV of heterosexual men, and it’s even worse for black MSM. One in two black men who have sex with men will get HIV in their lifetimes, relative to one in 11 white MSM.

We have effective methods of addressing HIV. We have condoms, and we know that treatment helps prevent HIV. Now we also have pre-exposure prophylaxis—PrEP. We have all these effective means of addressing HIV. There’s no reason that so many MSM should have HIV.

I thought there must be structural drivers of these disparities. In the US, LGBT populations have explicitly unequal rights, and I was interested in whether those drove the health inequities that I was seeing. Infectious diseases like HIV and STIs have a way of exposing these inequities, and hopefully addressing structural barriers and facilitators can help reduce unjust disparities.

What led you to begin looking at LGBT health beyond HIV and other STIs, like same-sex marriage legalization and adolescent suicide?

One reason was that we started to have data available indicating that LGBT populations experience a wide range of health disparities beyond HIV. The CDC had just started to include questions on whether adolescents were LGB—they still don’t collect information on T—in the Youth Risk Behavioral Surveillance data, and they started to put out studies on the disparities that they were seeing.

I focused on suicide attempts because it was one of the largest disparities, and I thought that was a natural first place to look. LGB youth were about five times more likely than their peers to report attempting suicide in the past 12 months. That itself is really heartbreaking.

I took advantage of this natural experiment created by geographic and temporal variation as states legalized same-sex marriage—starting with Massachusetts in 2004 and with more and more states passing it until it became legal across the country in 2015—to look at how changes in policies lead to changes in suicide attempts among youth.

It’s been really gratifying to contribute to the literature on LGBT health and how rights affect health outcomes. I hope to continue working on LGBT health disparities as well as to start looking at things like how criminal justice, housing, education, tax, and welfare policies affect racial and ethnic health disparities.

You mentioned the CDC beginning to gather data on LGB youth, but not transgender youth. What is the state of LGBT data in the US now?

Unfortunately, some of it has been rolled back, like with the Census and the National Survey of Older Americans Act Participants. That really takes away a public good. It’s an important thing to have those data and to make them accessible to researchers. It’s something that would benefit all of us.

I personally have been frustrated by the lack of representative data on transgender populations. We have little representative data on who’s transgender, but some states have started collecting transgender data through the Behavioral Risk Factor Surveillance System beginning in 2014, and the Massachusetts Youth Risk Behavior Survey is starting to collect it as well. With a small population, you really need data collection more broadly. I think that laws regulating restrooms, locker rooms, and military participation for transgender individuals are a top priority for study, but it’s very hard to study without the data. Population surveys, like the 2015 US Transgender Survey, are important, but it really should be a top priority to get these questions into the representative data sets that the US government collects in all 50 states. I’m doing what I can with the limited data available to study policies that affect LGBT populations right now. It’s important to do what we can with the data available.

In the face of limited data and new policies affecting minority groups, what are you hopeful about?

I’m hopeful for a lot of reasons. Especially in this moment, researchers are advancing rigorous research on how social policies affect people. There have been some great quasi-experimental studies on things like immigration raids and Deferred Action for Childhood Arrivals and how they affect the mental health of Hispanic populations.

There are a lot of questions to answer right now, and on the other hand there are some questions we’ve answered pretty well. We have a lot of evidence that Medicaid expansion has really benefited the health of populations who got Medicaid because of it, for example. What’s hard is providing evidence that appeals to everyone and really demonstrates the case across the population.

How do you make that jump from gathering evidence to convincing people?

That’s really important for public health researchers to be thinking about right now. In a polarized world, it’s good to focus on where we do agree. With the paper on same-sex marriage and adolescent suicide, there’s widespread agreement that we don’t want adolescents taking their lives.

Thanks to SPH encouraging it, I’ve also been prompted to do more work to translate my research into policy. Tomorrow I’m talking to policy makers about PrEP and why we should include it in the Massachuetts sex ed bill under consideration by the House Ways and Means Committee, because my research shows that young gay, bisexual, and other MSM are getting less HIV education than their peers. They have low awareness of PrEP even though it’s very effective for preventing HIV, and they deserve to know about it.

I noticed the bill included a lot of great things like LGBTQ-inclusive education, which is wonderful and a really great indicator of how progressive this state is. I think it’s natural to start including PrEP in sex education as well. We know many people aren’t learning about PrEP from their doctors, so school is a place to reach everyone. Everyone should learn how to protect their health, and PrEP is one approach to doing that.

If there’s a bill that’s relevant to my work, then I should take the opportunity to go talk to policymakers about the insight that I have based on my research. It’s been really great to be able to get advice from Dean [Harold] Cox on going about this. This is really what makes our work meaningful: translating it into change for people’s lives. I’m excited to be doing that here at SPH.

—Michelle Samuels