Inside the American healthcare debate, the Canadian system is often used in argument. But when you step away from the politics, one thing is clear: all Canadians have access to health care.

Canada’s LGBT Community greatly benefits from the Canadian healthcare system. Access to medicine, hospitals and preventative care keeps the rate of new HIV infections lower than many Western nations, according to a researcher.

In 2007, the number of Canadians living with HIV was 59,372 as compared to the United States which had 571,378 at the same time according to Avert, an international AIDS charity group. It’s statistically similar to the United States.

But the LGBT community might be underserved by the Canadian system according to Bill Ryan, professor of Social Work at McGill University in Montreal, who has been researching HIV and HIV prevention in Canada for nearly 20 years.

Ryan is an expert in the field of gay health and is a co-founder of the Rainbow Health Coalition. He believes homophobia in the system keeps gays and lesbians from seeking early medical treatment and preventative care.

“If we don’t do prevention, we’re just going to end up caring and supporting multitudes of gay and bisexual men,” Ryan said.

Ryan says the Canadian healthcare model mirrors the field of gay men’s health in Canada by focusing on demographic groups rather than only individual health care. The Canadian system encourages groups of people to look at their health needs as whole.

However, Ryan believes a lack of sensitivity affects gay people’s ability to stay healthy.

“Nobody is going to be refused because they’re gay, lesbian or bisexual,” Ryan said. “But that doesn’t mean necessarily that those that provide the service will be sensitive.”

Yves Lafontaine, editor of Fugues, and LGBT Magazine in Montreal, also said there isn’t an adequate amount of HIV prevention in Montreal.

The government conducts public testing and provides condoms to bars and saunas, but Lafontaine said that’s not nearly enough.

“There’s not always a cohesive strategy [in Canada,]” Lafontaine said. “The problem is more like structuring and integrating HIV prevention into a larger definition of sexual health for gay men,” Lafontaine said.

“The idea is to have better view of all the groups who are most at risk” he said.

However, if a gay person feels that a healthcare professional has discriminated against them because of their sexuality, they have recourse in every single province. All LGBT are protected from discrimination by human rights laws that are identical throughout each province.

Ryan believes if sensitivity issues in gay healthcare were tracked appropriately, it would increase the regularity of LGBT people’s medical visits. But he does believe that insensitivity in healthcare isn’t entirely malicious, but perhaps the result of insufficient training.

“Many people within the healthcare system still don’t feel that they have been trained adequately on these issues,” Ryan said.

Gay marriage is no big deal in Québec. It hasn’t been since it was legalized here on March 19, 2004, when the province became the third in Canada to allow full marriage benefits to same-sex partners. Sixteen days prior, Eliot Spitzer, then-New York attorney general, issued an informal statement announcing his state would recognize same-sex marriages from other jurisdictions.

And so Sharon Rozen, an event planner from Québec, had the idea to cater a business specifically toward same-sex couples from the United States, primarily those in New York, looking to take advantage of the new freedoms. Rozen is one of three partners that make up Toujour L’Amour, and they specialize in gay destination weddings in Montréal.

She said she doesn’t marry Québecquois gays and lesbians “because they could do it themselves if they wanted to.”

“Marriage is not a big thing in Québec,” added Aron Wohl, a notary who works with Rozen. “In the French-Canadian populations, it’s only something like 20 or 30 percent that get married. I think the same-sex is a little lower.”

There were 22,038 marriages last year in Québec, according to the Institut de la Statistique Québec, and only 455 of those were same-sex marriages. In the United States, 2,162,000 couples tied the knot in 2008, according to statistics from the Centers for Disease Control. (National data on same-sex marriage in the United States do not exist.) There are about 7.8 million people here in Québec, compared to 300 million in the United States.

“Québec has the lowest percentage of people who get married in the country,” said Tanya Churchmuch, a Tourisme Montréal manager who focuses on LGBT travelers. “People tend to shack up here a lot more than actually go through the entire process of getting married. Common law marriage has the exact same recognition as ‘marriage marriage’ does. ‘Marriage marriage’ is a lot more symbolic than it is practical, which is very different than the U.S.”

This is a fact Rozen has built her business around and a reason why Churchmuch said “it’s not actually one of our priorities.”

Rozen said while the impact of lesbian and gay Americans coming to Montréal to get married isn’t too noticeable economically, it’s certainly taking money away from her clients’ home states.

“The people who are coming here to get married are upper to middle class people, who have the resources and who want to spend their money to get married,” she said. “And the point is they can spend it here or they can spend it at home, but they’re spending it here partially because it’s a destination but partially because their home won’t let them.”

She organizes about one same-sex marriage each month, and she’s been doing weddings for same-sex partners since around the time New York began recognizing same-sex marriages. Most of the Americans come from New York or other Northeastern states where gay marriage is either legal or recognized.

She likes to ask couples why they chose Montréal, when “you can get married at breakfast. You can get married at dinner. You can have a Thai tea. You can have anything you could possibly imagine, and it can be done.

“I think they come to Montréal because it’s a very romantic, European-type city. They’re looking for legal marriage rather than civil union or some other thing. Most people have a positive association with visiting Montréal. In some cases, the couple met in Montréal, or they had visited Montréal.”

So who’s seeking out her services and the perfect wedding in a foreign, yet accessible city?

“The people who are choosing to get married who are gay are similar to straight people in Québec in the sense they’re more conservative,” Rozen said. “It’s a stabilizing factor that they have a long-term commitment to each other. They may or may not be planning to be having children or to adopt children. They have a family, and this is just a process in recognition of that.”

This may or may not have something to do with the long-standing Québec tradition of mandatory posting of wedding banns at least 20 days before a wedding, same-sex or otherwise. As Wohl explained, copies of these provincial announcements hang on a post at the courthouse. Even though you don’t have to be in Québec for the duration of the waiting period, Churchmuch explained it does put a damper on the city’s attractiveness for many looking for a more immediate arrangement, and as a result there aren’t “a lot of quickie marriages here in Québec.”

“We’ll have people come a few months ahead of time, search out their venue,” Churchmuch said. “They’ll determine who they want to marry them. They’ll figure out those kinds of things. They’ll visit caterers, and then they’ll come back two months later for their actual wedding, which is very different than people who are coming to Toronto who decide almost Vegas-style that, ‘Oh my god, it’s legal, let’s get married.’”

Because those who typically work with Rozen aren’t simply looking to get hitched, she puts great attention to making each ceremony special. “It’s like organizing your child’s or your relative’s wedding,” she said. “You want every detail to be perfect at every level.

“You can get married in about five minutes here. The notary just reads a few articles. That’s the legal requirement. Everything else is what’s meaningful for the couple.”

Everything else from the after-party, which Rozen said one couple is currently planning on spending at Cabaret Mado in Montréal’s gay village, to if or how much of the partners’ families attend to the ceremony.

“We’ve had people who come with their entire family,” she said. “We’ve had one side show up, and the other side will not. And then we have people who don’t come with their family, and that’s a different tone.”

The ceremony should be entirely up to the couple, Wohl said, but part of it is a function of who’s attending. “At the beginning, we had a couple from New York who came with both their families,” he said. “It was before it was recognized in New York, and the parents of both were just in tears. They were so thankful they could do this here. It was just 20, 25 people. It was very touching.”

And both Rozen and Wohl are aware of the duality of the ceremonies in which they prepare and participate. Yes, they’re sacred commitment ceremonies, but “it is basically demanding certain rights and having them, when others still don’t have them in certain places,” Rozen said.

“I think, in terms of gay marriage, the couple tends to be more moved in a sense because it’s something that’s new that they couldn’t do in the past,” Wohl added. “It’s like a political statement they can take advantage of.”

But it doesn’t seem to be a platform any native gays or lesbians are rushing, en masse, to take up. “Montréal just generally is a very welcoming destination for the LGBT community, and historically, has always been known as that,” Churchmuch said.

“Montréal is kind of a destination where people will come here because they know they can be themselves, but also once they get, it’s an amazing city – you have Old Montréal, you have people speaking French – it’s basically a different destination than anywhere else in North America. It’s kind of like you have this opportunity to get the old European charm, hear a foreign language and you can be totally gay, you know?”

So while it might feel underwhelming to Americans to whom the Québecois attitude may come off as offensively casual, “it’s just a normal part of society,” Wohl said.

Churchmuch said her organization is simply looking “to really have people come in and enjoy themselves.” They’re not advertising in wedding magazines — they’re just maintaining a very LGBT-friendly image. Whether they’re getting married or just vacationing, 6 to 7 percent of tourists coming to Montréal are LGBT, but they make up 10 to 11 percent of tourist spending here.

“If you get married here, we’re so happy you get married here,” Churchmuch said. “If you just want to come and visit, we’re happy you want to come and visit.”

There is no issue with gay marriage. No fuss, no uproar, no polarizing dichotomy. What those in the United States are still selling as one of the top issues on the LGBT agenda, Canadians have been operating and living out for half a decade. “It’s pretty open,” Rozen said, “which is sort of the way it should be.

“If someone is involved in a relationship, and they are committed to someone else, they feel marriage is appropriate for them, then they should be allowed to marry. That’s sort of the position the state takes.”

Listen: NLGJA InSight reporters Mandi Rice and Ryan Mclendon go to the mat covering a local naked yoga class.

Canada has granted gays and lesbians more equal rights than the United States for years now, including same-sex marriage and allowing LGBT soldiers to serve openly in the military. Even with those advances, though, experts say homophobia is far from dead and still hurting gay youth.

Kathleen Weil, Quebec’s minister of justice, is pushing a government policy against homophobia after a commissioned report from the former provincial justice minister showed that gay and bisexual youth were six to 16 times more likely to commit suicide than their heterosexual peers.

That’s more than double American statistics.

The Trevor Project, an organization focused on crisis and suicide prevention efforts among LGBT youth in the United States, cites a 2006 Massachusetts study that said gay youth are up to four times more likely to attempt suicide. Numbers from the Centers for Disease Control and Prevention are just below that.

Philippe Archambault, press secretary for Weil, said Quebec has always been open and one step ahead of other governments, and the proposed policy against homophobia is another example of that.

“We’ll be one of the first states in North America to have that kind of policy,” he said. “There will be a lot of publicity. It’ll be a big thing against homophobia in Quebec.”

Beansie Saretsky, a junior at McGill University, is a member of the school’s gay student group, Queer McGill. Growing up in Calgary in western Canada, she said she appreciates living in an urban area like Montreal that’s more accepting.

“Montreal is a great city to be queer in because it is very open and there are plenty of opportunities to socialize and be with people who are like you in an open environment,” Saretsky said, “compared to places on the prairies, where you might feel more uncomfortable being out in public.”

Gai Écoute, or Gay Line in English, is a center with phone lines for information and help for gays and lesbians in Quebec. Director Laurent Gosselin said statistics on gay youth suicide differ in numerous surveys.

The organization compiled its own information from one survey done in Calgary that showed 62.5 percent of young men who had attempted suicide were gay or bisexual, while gays only made up 13 percent of the total sample.

That 1997 study concluded that young gay and bisexual men ages 18 to 27 were 14 times more likely to attempt suicide than their straight friends, which Gai Écoute said was in line with a 1978 study that said young gay men were 13 times more likely to make a suicidal act.

Saretsky said she didn’t begin identifying as gay until she got to college, but said she rarely saw same-sex couples on the Calgary streets, and knew of only one gay club.

“It’s harder to meet people I think,” she said. “It’s a big city, but there isn’t much gay culture. People aren’t openly hostile or anything, but it’s not as welcoming as it is in Montreal.”

The Canadian Association for Education and Outreach in Quebec provides services for Montreal’s English-speaking LGBT community, including a phone hotline and SILK – Sexual Information Leads to Knowledge – where the group talks to students in the city’s 65 English schools.

CAEO Quebec President Nick Frate said they don’t get many calls from youth contemplating suicide – there were three in the last 12 months – but he said there are numerous suicide hotlines across the area, including the city’s own.

But with regards to the statistics, Frate said homophobia is a problem in the rest of Quebec, not the city. There are 7 million people in the province, and four million of those people live in Montreal, he said.

“There’s still a lot of homophobia in the (outer) region where they may not have any gay bars, let alone gay-straight alliances in their schools,” Frate said.

Line Chamberland, sexology professor at the University of Quebec at Montreal, is finishing up a study for the human rights commission on homophobia in schools. While not yet complete, she said it appeared that a quarter of all students are in one way or another victimized on the basis of their sexual orientation or perceived sexual orientation.

Chamberland said gender non-conformity is falsely interpreted as homosexuality and a cause of ridicule and bullying, but she said there have been studies in Quebec indicating the stress adolescents and their families go through in those situations when living in small cities or villages.

“In a big city it’s more anonymous,” Chamberland said.

Fred Kuhr, a writer for Press Pass Q in Toronto, echoed Frate and Chamberland in saying there is a “grand rural-urban divide in Quebec and all of Canada.

“Yes, in metropolitan areas like Toronto and Montreal there are huge amounts of understanding and acceptance,” Kuhr said, but outside of those cities, “(the gay) experience can be very different.”

Imagine that after years of hiding your sexuality from everyone you know, it was demanded that you prove yourself gay to government authorities to begin a new life in a new country. Gay refugees seeking asylum in Canada to escape persecution by their home governments are asked to do just that and are sometimes unsuccessful, placing their lives in greater danger.

“A lot of newcomers don’t know how to prove they are gay by North American standards,” said Aamer E., project coordinator for Among Friends, a gay refugee rights group. He also mentioned the lack of rainbow flags and what would be considered “gay clothing” owned by refugees.

Among Friends is a program to improve access to services for lesbian, gay, bisexual, trans, and queer refugees and immigrants in Toronto. The group also helps refugees seek safety in Canada from their home countries.

Aamer said all refugees making a claim have to address two or three specific areas for consideration to stay in Canada. Claimants must: explain why they chose Canada; detail the level of persecution they will face if they stay in their home countries; and prove their sexuality, if that’s grounds for the claim.

How does one prove his or her sexuality?

“You have to have pictures,” Aamer said. “Go to the gay bar, take pictures with the drag queen. Dress gay. All of the things that we on the street would identify … as gay.”

Aamer said he and other Canadians see one big flaw with this process of proving one’s sexuality, “It’s based on assumption and stereotypes,” he said.

However, Stéphane Malépart, senior communications advisor for the Immigration and Refugee Board of Canada, said review board members “receive specific training on how to handle refugee protection claims based on sexual orientation” that includes “warning against stereotyping.”

Refugees can also present love letters or e-mails from past same-sex lovers, testimony from past same-sex partners and testimony from family to prove their sexuality.

This type of evidence is often missing because of its sensitive nature in a country that could imprison or kill a person for his or her homosexual lifestyle, Aamer said.

The decision about one’s sexuality is ultimately decided by one judge who sifts through the evidence presented.

“Each case is decided specifically and impartially based on the claimant’s testimony, the documentary evidence provided by the claimant and the living conditions in the country of origin,” Malépart said in an e-mail.

But as the claimant is standing before the judge, Aamer believes that it is a snap decision about the person’s sexuality based upon appearance.

The most recent gay refugee claimant to be returned to his home country was Kulenthiran Amirthalingam, who was sent back to Malaysia in March 2008 after the judge declared his homosexuality was not credible.

Legal experts in Canada say that because of the unclear guidelines for proving one’s sexuality, the Canadian Refugee Board needs to establish clearer standards on sexual orientation.

Some people seeking asylum in Canada try to get in by falsely claiming they’re gay, Aamer said, making scrutiny by the refugee board more strict.

“The people making honest claims end up getting messed up in this process,” Aamer said.