So how are social inequalities reflected in LGBT+ health? There is an abundance of research pointing at the existence of health inequalities. Starting with mental health, a 2008 systematic review which mainly looked at US data, suggested that LGB populations have significantly poorer mental health compared to heterosexuals. Examples include an increased risk of suicidal thoughts and suicide attempts, alcoholism, and drug dependence. Similarly, a UK study pooling data from 94,818 participants from within twelve population surveys, found that lesbian women and gay men were at higher risk of poor mental health than heterosexuals (particularly those aged under 35 and those aged over 55), while bisexual participants were at even higher risk of poorer mental health.
These trends are even more dramatic within the trans community, which produces some extremely worrying statistics on suicide and mental health, however overall, research is sparse and there are no UK population studies. If surveys recorded data on gender identity, we could have much higher quality evidence today.
Health inequalities are also prevalent in physical health. Smoking and alcohol misuse is more likely to be reported by lesbian women and gay men than heterosexuals (for bisexuals this is only the case with smoking). A study on sexual orientation identity and Body Mass Index will be published soon, showing that lesbian women are at increased risk of being overweight/obese and gay men of being underweight.
These effects are further exacerbated by the fact that LGBT+ individuals often delay or even avoid accessing healthcare to avoid stigma, which qualitative data suggest can manifest itself as homophobic and transphobic behaviour in UK health services. Even when LGBT+ individuals approach healthcare professional they can be met with a lack of knowledge and understanding of LGBT+ health issues.
Dr Rachael Jones
Dr Rachael Jones was appointed Consultant in HIV/Sexual Health at the Chelsea and Westminster Hospital Foundation Trust in 2007, becoming clinic lead at the West London Centre for Sexual Health, now 10 Hammersmith Broadway, soon after. Rachael’s major interests are the medical complications of HIV, particularly renal disease. In the field of sexual health, Rachael has developed multiple outreach projects designed to target vulnerable individuals, in order to normalise screening and reduce the prevalence of undiagnosed HIV/STIs and unwanted pregnancies. She has been involved in writing local and national guidelines on HIV and sexual health. She is on the board of St Stephens AIDS Trust and the British Association for Sexual Health and HIV.
What is sexual health?
Often when we use the term sexual health, we encompass physical, emotional, mental, and social wellbeing, rather than merely the absence of disease, dysfunction, or infirmity. Sexual health or “Venereal Disease” clinics were established in 1916 following the Public Health (Venereal Disease) Regulations 1916. Attendance was voluntary, and patients were treated for free and in confidence.
Modern sexual health services – genitourinary medicine (GUM) – comprise a very wide range of services that continue to adapt to changes. For example a modern GUM clinic offers a range of core services including disease surveillance and screening, partner notification, contraception, sexual health promotion, diagnosis and treatment, training, teaching, and research.
Additional services offered by some larger clinics:
- psychosexual services
- genital dermatology
- drug and alcohol support
- preventative measures (such as pre-exposure prophylaxis for HIV)
- sexual abuse support
- adolescent care
- management of cervical and anal cancers
In terms of what works well, accessible services are key. Chelsea and Westminster NHS Foundation Trust runs several community-based services. The Dean Street clinic in Soho is well situated for delivering care to its target population. Embracing technology in delivering care has proved invaluable, for example some patients are more likely to give relevant information about their needs when asked using a computer touch-screen than face to face. Similarly, improved diagnostic technologies mean that clinicians can access fast test results and expedited treatment for patients, and improve knowledge about at-risk populations.
An often cited success story is the ongoing drop of new HIV diagnoses in the UK, as a consequence of education, health promotion, better access to testing, more testing, early treatment, and access to PrEP (Pre Exposure Prophylaxis for HIV). Still, many challenges remain, such as the rising rate of some sexually transmitted infections, notably syphilis and gonorrhoea, which had both increased by about 20 percent in England in 2017. Groups at most risk include young people aged 15-24, and men who have sex with men. Notably the STI rate in London is 83 percent higher than all other regions. While this rise in STIs might be partly explained by the use of PrEP and the abandonment of condoms, closure of STI services is likely also affecting rates.
Health4LGBTI is an EU-funded programme studying health inequalities and barriers faced by the LGBTI community and developing the tools that healthcare professionals need to overcome these barriers. The project team comprises of five centres: EuroHealthNet (Belgium), Verona University Hospital (Italy), University of Brighton (Centre for Transforming Sexuality and Gender, UK), the National Institute for Public Health-National Institute of Hygiene (Poland), and ILGA-Europe (the European region of the International Lesbian, Gay, Bisexual, Trans, and Intersex Association). Healthcare professionals assume that LBGT+ people’s health needs are the same as those of heterosexual people but this is not the case. Many health inequalities are preventable and the project recommends that EU member states should develop services that are equally accessible to all.
The project was divided into five tasks:
- global literature reviews on LGBTI health and healthcare inequalities
- focus groups in six countries
- development of training modules
- pilots for training modules in six countries
- dissemination of results
Minorities within minorities
People may have multiple identities that can be a source of support but also be linked with isolation.
The LGBT+ community is one of dynamism and variety. Different sub-groups within it all have different needs, and the issues impacting for example gay men may not be impacting the rest of the community in the same way. For example, particularly within the women who have sex with women group we see very strong trends of bi-erasure and the resulting invisibility of bisexual women.
When it comes to trans and non-binary communities, we have very different issues at hand: we don't know how many trans people there are or how big the extended communities are; we don't understand them and when we study them we tend to focus on the heterosexual subset within these communities.
In an ideal world having multiple identities should be amazing, but in real life they can become reasons for isolation.
To reach these minorities within minorities, a key strategy is to use a community-centred approach in which LGBT+ people are involved in the work of high level Boards within PHE, and feed into decision-making.