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LGBT+ Health Inequalities Parliamentary Office of Science and Technology

Dr Sarah Bunn, Lef Apostolakis | Parliamentary Office of Science and Technology

Overview

There is emerging evidence demonstrating that lesbian, gay, bisexual, trans, and other minority sexuality/gender identity groups (LGBT+) experience significant health inequalities across their lifespan, often starting at a young age. For example, LGBT+ people are at higher risk than their heterosexual peers of poor mental health, self-harm, and suicidal behaviour. These inequalities result in poor physical and mental health conditions that persist into old age. Discrimination and prejudice shape the LGBT+ community’s experiences of and access to healthcare systems.

The lack of high quality evidence, has meant that healthcare providers and policymakers have been unable to understand health risks and inequalities. Notable exceptions include the management of HIV, which has shown that extensive study of the affected population and user-centred service design can have positive results.

To explore the challenges that members of the LGBT+ community face within the healthcare system, POST (the Parliamentary Office of Science and Technology) in collaboration with parliOUT (UK Parliament's LGBT+ workplace quality network) invited academics to present their latest research on health inequalities and discuss evidence-based interventions. We brought clinicians to discuss the challenges and opportunities in delivering care for LGBT+ communities in NHS services. We encouraged representatives from Public Health England to take us through the latest Government research and policy aimed at improving the health of these groups.

The Panel: (from left to right) Dr Joanna Semlyen, Dr Tristan Barber, Dr Rachael Jones, Thangam Debbonaire MP, Luis Guerra, Dr Laetitia Zeeman

Thangam Debbonaire MP

Thangam Debbonaire, acted as chair and moderator of the panel discussion.

Thangam became the Member of Parliament for the Bristol West constituency in May 2015, transforming a Liberal Democratic majority of 11,366 into a Labour one of 5,673. She moved to Bristol to be Women’s Aid’s first ever National Children’s Officer, setting up support projects in refuges across the UK for children. Treatment for breast cancer (diagnosed in June 2015) kept her from the House of Commons during the second half of 2015, but she very recently began a gradual return to Westminster and is looking forward to working at full steam again. Thangam is the chair of the All-Party Parliamentary Group on Refugees and her topics of interest include housing, climate change, science and research, and autism.

Dr Joanna Semlyen

Dr Joanna Semlyen is a British Psychological Society Chartered Health Psychologist and a Public Health Specialist. She is an academic based at Norwich Medical School at the University of East Anglia with expertise in gender and sexual minorities. She has published a series of articles and book chapters in the field of LGBT+ health and has produced the first population level analysis of the relationship between sexual orientation and common mental disorder in the UK.

How big is the LGBT+ populations in the UK?

Although some estimates exist, the most recent modelled estimate by Public Health England in 2017 using various survey data gave a range of 0.9 to 5.52 percent of the population being LGBT+, giving a weighted estimate of 2.5 percent. The lack of certainty could be a result of the variety of methods implemented by surveys. Answers may differ depending on whether the survey is conducted face to face, online, or in writing, as well as on how questions on sexual orientation are phrased. Are participants being asked what their identity is, who they are attracted to, or how they behave?

A great opportunity to better establish the size of the UK's LGBT+ population, will be the Census of 2021. For the first time questions on sexual orientation (SO) identity and gender identity may be included.

How do health inequalities emerge?

Members of the LGBT+ community still face toxicity and hostility in many aspects of social life. Often across their lifespan, LGBT+ experience prejudice and rejection from their family, friends, teachers, and employers, for reasons ranging from intolerance and disapproval of their identity to severe homo/transphobia.

These social attitudes are often translated into health inequalities when for example conservative, heteronormative, or outright homophobic attitudes are found among health professionals, making healthcare hostile. This effect is exacerbated by LGBT+ lifestyles: nightlife has traditionally provided safe spaces for members of the LGBT+ community, however such spaces and behaviours are often connected to alcohol and drug use.

The research evidence

The reality is that in the majority of cases, the research evidence on LGBT+ health inequalities is of low quality, consisting of 'convenience samples' which are not representative. However, recently there have been some improvements, with a few longitudinal cohort studies and cross-sectional health surveys now asking a question on sexual orientation. Still, major issues persist, such as the lack of questions on gender identity, and the resulting lack of data.

In 2009, The Office of National Statistics asked 'Which of the following options describes how you think of yourself? Response options included: Heterosexual or Straight, Gay or Lesbian, Bisexual, Other, I don't want to asnwer.
Image Credit: Joanna Semlyen

Health consequences

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
  • outreach
  • 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

Effective service

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.

Image Credit: Rachael Jones, Public Health England, Barts Health NHS Trust, Ordnance Survey

Rachael highlights the increased pressure on services due to clinic closures, reduced opening hours, and budget cuts of up to 30 percent. Some services have restructured in response, but even so, find themselves unable to provide the same level of care. The greatest impact seems to be on testing and appointment access, which is significantly constrained. It also means that patients are likely to experience longer waits to access care; this could have consequences for STI rates, health of the population, and rates of unplanned pregnancies.

Dr Tristan Barber

Dr Tristan Barber is currently a Consultant Physician in Sexual Health and HIV at Chelsea and Westminster Hospital, and an Honorary Senior Lecturer at Imperial College London. He is Chair of the BASHH HIV Specialist Interest Group (SIG), Treasurer of the Gender and Sexual Minorities SIG, and also Chair of the BHIVA International Partnerships Working Group, part of the Education and Scientific Subcommittee. He has a research background in HIV related neurocognitive impairment and phase III clinical trials. He is currently Lead Clinician for the John Hunter Clinic and is passionate about LGBT+ health having established a specialist clinic for LGBT+ service users that has now been running for over three years.

Specialist services

The LGBT+ community is extremely diverse and has similarly diverse needs. This is why there is a range of specialist services offered by Chelsea and Westminster NHS Foundation Trust. For example, cliniQ is a service for trans individuals, in partnership with the Dean Street clinic. 84 percent of trans people have thought about suicide, while 48 percent of trans people have attempted suicide. One meta-analysis found that trans women have a 49 percent higher likelihood of acquiring HIV. CliniQ offers a sexual health service as well as hormone therapy and cervical screening.

Unfortunately there seems to be a poor level of awareness of HIV prevention intervention in the trans community and a low willingness to take PrEP. This demonstrates that there needs to be increased visibility of trans people and their partners in both general and PrEP-specific health campaigns. There is also a requirement for better clinical knowledge of trans issues.

Currently, the John Hunter Clinic on the main Chelsea and Westminster site runs an LGBT+ weekly specialist sexual health service, called Refresh. All medical and non-medical staff are trained on LGBT+ sexual health issues and some club-drug issues. Patients express satisfaction with the service, with 81 percent rating it as excellent, and the majority feeling that they are treated with respect and dignity.

These open access services are really important and are often the first point of contact for a wide range of health needs, including specialist sexual health services. Currently, these services are being threatened by lack of funding and commissioning decision, while there is also underdeveloped specialist primary care for the LGBT community.

Dr Laetitia Zeeman

Dr Laetitia Zeeman has extensive experience of healthcare governance, education, and research gained in the UK and Southern Africa. Her research with Prof Nigel Sherriff at University of Brighton for the European Commission and Local UK Council addresses the health and social inequalities of lesbian, gay, bisexual, trans, and intersex people where health promotion is understood in the context of boarder systemic policy and practice change needed to address inequality.

Health4LGBTI

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

The main findings from the literature review reveal that LGBT individuals face significant mental and physical health inequalities and are at particular risk of mental illness compared to the general population. They are also at risk of poorer physical health, with evidence for a higher risk of some cancers at a young age. All risks are dependent on age, socioeconomic status, gender, and geographical location, and vary between LGBT groupings.

Cultural and social norms also prioritise heterosexuality, with health services designed and operating with that group in mind. Homophobic discrimination is widely reported, with eleven of the 28 EU member states offering conversion therapies. There are 72 states globally in which same sex activities are criminalised.

Health barriers

When trying to access healthcare services, LGBTI people may encounter a variety of barriers such as poor communication by health professionals, cultural or social norms that assume heterosexuality, the fear of coming out and possible hostile reactions by health professionals, and lack of knowledge about LGBT needs amongst health care professionals. Health4LGBTI has found that LGBT people reported being refused care, particularly trans people, and that healthcare professionals found it difficult to challenge negative attitudes amongst colleagues. LGBT people found it useful to see services identifying as being LGBT friendly.

Training modules developed by the project have recognised that changes in language are important and that LGBT people should be included in policy and decisions about healthcare delivery related to their needs. It also identified that anti-discrimination laws which cover health be adopted, so that LGBT healthcare is part of mainstream health services. Training for health professionals and student curricula is needed to enhance cultural competence and knowledge of LGBT health needs and should be reflective of current data and research. And of course, legal protection and recognition (for example the UK Equality Act 2010) is an important measure to prevent discrimination on grounds of sexual orientation and gender identity.

Luis GueRra

Luis Guerra is the National Lead on Sexual Health, Reproductive Health and HIV Prevention at Public Health England. He oversees the development, delivery, and evaluation of the national programmes to improve sexual health outcomes and reduce health inequalities. Luis has published on sexual health, mental health, and physical activity. Before joining the government sector, he worked in the community sector in the UK, USA, and Peru. Luis is the current chair for PHE’s LGBT Network (PHERA) and has been recognised in the LGBT Civil Service index awards and as PHE’s diversity champion for his work addressing health inequalities in ethnic minority groups and LGBT communities.

Being gay is amazing. it is powerful. Being part of the LGBT+ spectrum is good.

Public Health England

The debate on LGBT+ Health is dominated by a deficit based narrative that perpetuates stereotypes. Study data consistently showes inequalities, but is of variable quality and sometimes conflicting. Men’s health predominates the field, with a focus on HIV and STIs, which is reflected in the recent advances in HIV prevention.

Various reports have been published recently, notably the Government’s LGBT Action Plan, based on data collected from 108,000 people. Public Health England (PHE) published a review of health inequalities for men who have sex with men (MSM) in 2014. The three key health inequalities were:

  • mental health and wellbeing
  • alcohol, drugs and tobacco use
  • sexual health and HIV

Inequalities for lesbian, bisexual women and other women who have sex with women (WSW) were:

  • mental health
  • pregnancy and reproductive health
  • some cancers
  • alcohol, drug, and tobacco use
  • intimate partner violence
  • musculoskeletal and respiratory conditions

For trans and non-binary communities the inequalities are focused on:

  • mental health
  • alcohol, drug, and tobacco use
  • violence.

This group was a focus for significant discrimination. PHE will publish a report of the first national survey of trans reproductive health in 2018/19.

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.

A range of stakeholder organisations are currently involved in the co-production of knowledge and are building toolkits to facilitate improvements. These include the National LGBT Partnership, the National LGBT Academic & Research Network, cross-Government partnerships, and various advisory boards within PHE and at community levels. There are a number of PHE projects to build the evidence base including systematic reviews and work to establish the national LGB prevalence. The are also specific projects looking at minority groups, and developing corresponding action plans.

we need to start adapting to challenges to the binary construct and we need to start demonstrating value for money.

* This account of the event has been edited for clarity and brevity. The full account and discussion that followed, as well as the speakers' slides will be made available on the POST website shortly.

Further reading

King, M., Semlyen, J., Tai, S. S., Killaspy, H., Osborn, D., Popelyuk, D., & Nazareth, I. (2008). A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC psychiatry, 8(1), 70.

Hagger-Johnson G, Taibjee R, Semlyen J, Fitchie I, Fish J, Meads C, et al. (2013) Sexual orientation identity in relation to smoking history and alcohol use at age 18/19: cross-sectional associations from the Longitudinal Study of Young People in England (LSYPE). BMJ Open.

Semlyen J, King M, Varney J, Hagger-Johnson G. Sexual Orientation and Symptoms of Common Mental Disorder or Low Wellbeing: Combined Meta-Analysis of 12 UK Population Health Surveys. BMC Psychiatry. 2016; 16:67.

Semlyen J.et al (2018, under review) Sexual orientation identity in relation to unhealthy Body Mass Index (BMI): Individual Participant Meta-Analysis of 93,429 individuals from 12 UK health surveys

Zeeman, L., Sherriff, N.S., Browne, K., McGlynn, N., Aujean, A., Pinto, N., Davis, R., Mirandola, M., Gios, L., Amaddeo, F., Donisi, V., Rosinska, M., Niedźwiedzka-Stadnik, M. & Pierson, A. (2017b). State-of-the-art synthesis report on the health inequalities faced by LGBTI people in Europe. Luxembourg, European Union.

Zeeman, L., Sherriff, N.S., Browne, K., McGlynn, N., & Aujean, S., et al., (2017a). Scientific review: A review of health inequalities experienced by LGBTI people and the barriers faced by health professionals in providing healthcare for LGBTI people. Luxembourg: European Union.

Zeeman, L., Sherriff, N.S., Aujean, S., Pinto, N., & Browne, K., et al., (2017b). Comprehensive scoping report: A review of the European grey literature on health inequalities experienced by LGBTI people and the barriers faced by health professionals in providing healthcare for LGBTI people. Luxembourg: European Union.

McGlynn, A., Browne, K., Pollard, A., Sherriff, N.S., & Zeeman, L., et al., (2017). Focus groups studies with LGBTI people and health professionals in six European countries. Luxembourg, European Union.

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