Submission to Women and Equalities Committee on LGBT Health Inequalities October 2018

Written evidence submitted by Dr Joanna Semlyen to Health and Social Care and LGBT Communities Inquiry

About Dr Semlyen:

Dr Joanna Semlyen is a Senior Lecturer in Psychology and Medical Education based at Norwich Medical School at the University of East Anglia. She is a Health Care and Professionals Council (HCPC) Registered Health Psychologist, a British Psychological Society (BPS) Chartered Psychologist, and an Associate Fellow of the British Psychological Society. She has a further role as a LGBT Public Health Specialist for Hertfordshire County Council.

Dr Semlyen has been carrying out research in the health of minority groups and vulnerable populations for the last 15 years and is a leading expert in the area of health inequalities in gender and sexual minorities.

Her research and professional profile is available at http://www.uea.ac.uk/medicine and at Researchgate[1].

Executive summary

  • This submission relates to evidence on health disparities in lesbian, gay, bisexual and trans (LGBT) population in the United Kingdom.
  • No accurate measure of the size of the LGBT population is available. Public Health England modelled estimate is 2.5%.
  • Majority UK LGBT health research – lower quality ‘convenience samples’.
  • Studies that compare LGBT to heterosexuals from a representative population sample offer significantly increased evidence quality.
  • Recent improved UK evidence base – few longitudinal cohort studies and population health cross sectional surveys – include the Office for National Statistics question on sexual orientation (SO).
  • No question on gender identity has been included (GI) = no population data on health inequalities for trans people.
  • There is wide evidence that LGBT people experience both mental and physical health inequalities, due in part to increased health risk behaviours and demonstrate poorer health outcomes.
  • Known variation in NHS standards of care received by LGBT people.
  • LGBT population avoid and delay in accessing healthcare and qualitative data shows experiences of heteronormative and homophobic health services care and transphobic health screening.
  • Lack of knowledge and understanding about LGBT health issues in health care professionals.

 

  1. LGBT population

1.1 Lesbian, gay bisexual and trans (LGBT[2]) population estimates

We do not have an accurate measure of the number of LGBT people in the UK to inform policy and practice in LGBT health and social care. At the time of writing this report a question on Sexual Orientation (SO) identity is available for adoption in the 2021 Census[3] but one on Gender Identity (GI) has yet to be developed by the Office for National Statistics[4]. It is not yet decided as to whether the Census will collect this SO and GI data in 2021 and, although likely to be an underestimate, if the Government wants to address the LGBT health and social care disparities experienced by the LGBT population, an accurate picture of the size of the population affected would be a fundamental requirement for targeting resources and developing interventions.

In representative national health surveys where sexual orientation is measured, around 3% select a sexual orientation identity other than heterosexual (Semlyen, King et al. 2016) although this can also be lower depending on how the question is asked. For example, when anonymity is provided by the internet, 5.7% of respondents identified as lesbian, gay or bisexual (LGB) (Ellison and Gunstone 2009).

  • Attraction, behaviour or identity

Sexual orientation encompasses three dimensions: sexual identity, attraction
and behaviour. Recent modeled estimates suggest that LGB people form 2.5–11.5% of the UK population (Geary, Tanton et al. 2018) depending on how the question is asked (attraction, behaviour, identity). Indeed figures are higher when sexual identity is measured by behaviour or attraction (Johnson, Mercer et al. 2001).

The best estimate we have, based on all recorded responses to UK surveys (a range of between 0.9%-5.52% LGBO[5]), is a weighted estimate of 2.5%

  • Trans population estimates

There is no agreed question for collecting data on minority gender identities although one is in development by the ONS4. Thus there are no representative research findings which have collected data on the trans population, although in one report, carried by the Equality and Human Rights Commission, they found 0.4% respondents selected a gender other than male or female when offered the option[6]. In a self-selected sample, 29% of respondents to the trans mental health study carried out by Scottish Transgender Alliance identified as non-binary (McNeil, Bailey et al. 2012).

  1. Mental health disparities for LGBT

From a systematic review of all existing evidence (looked at 13705 studies) carried out a meta-analysis of 25 included studies found higher risk of mental disorder, suicidality, and substance misuse in LGB (King, Semlyen et al. 2008).

 

Key data (King et al 2008) in summary: (LGB v Heterosexual, population study)

Two fold excess in suicide attempts in lesbian, gay and bisexual people

Four fold excess in suicide attempts in gay and bisexual men over a lifetime

Two fold excess in suicidal ideation, self-harm and depression in lesbian, gay and bisexual people

Three fold excess in drug dependency in lesbian, gay and bisexual people

Four fold excess in alcohol dependency in lesbian and bisexual women

 

2.1 Mental health disparities for LGBT in the UK

The author has recently carried out a review[7] of all evidence in the UK with data on LGBT mental health disparities (study has a comparative group) finding clear evidence of poorer mental health in LGBT people than heterosexuals. Data for LGB and for trans/non-binary populations will be presented separately.

2.2 Mental health disparities for LGB in the UK

In summary, the evidence collated shows poorer mental health in LGB respondents when compared to heterosexual respondents (McNamee, Lloyd et al. 2008, Chakraborty, McManus et al. 2011, Semlyen, King et al. 2016, Woodhead, Gazard et al. 2016). It also found higher rates of low well-being (Semlyen, King et al. 2016, Woodhead, Gazard et al. 2016), substance misuse (Hagger-Johnson, Taibjee et al. 2013, Pesola, Shelton et al. 2014, Mercer, Prah et al. 2016, Woodhead, Gazard et al. 2016), eating disorders (Calzo, Austin et al. 2018) anxiety (Jones, Robinson et al. 2017) and self-reported longstanding psychological or emotional problems (Elliott, Kanouse et al. 2015) in LGB participants than the heterosexual comparison group.

Poorer mental health was found to be twice as high for UK lesbian, bisexual, gay and otherv identified population in a representative sample (Semlyen, King et al. 2016) and that rates of mental disorder were found to be higher in younger people (Semlyen, King et al. 2016) and older (over 55) (Semlyen, King et al. 2016).

Key data (Semlyen et al 2016) in summary: (LGB v Heterosexual, population study)

Lesbian/Gay > mental health disorder than Heterosexual

  • under 35 (OR = 06, 95 % CI 1.60, 2.66) – two fold increase
  • non significant at age 35–54.9 (OR = 1.03, 95 % CI 0.71, 1.48)
  • strongest at age 55+ (OR = 11, 95 % CI 1.16, 3.83) two fold increase

[Bold indicates significant difference]

2.3 Mental health disparities for bisexual people in the UK

 

There is very little research looking directly at bisexual mental health. A recent representative population study has found that bisexual mental health is poorer for men and women (Semlyen, King et al. 2016).

Key data (Semlyen et al 2016) in summary: (LGB v Heterosexual, population study) 

Bisexual > mental health disorder than Heterosexuals (and L/G).

  • under 35 age group (OR = 31, 95 % CI 1.83, 2.90) two fold increase
  • age 35 to 54.9 (OR = 1.80, 95 % CI 1.29, 2.50)
  • strongest at age 55+ (45, 95 % CI 1.58, 3.79) two fold increase

[Bold indicates significant difference]

2.4 Mental health disparities for trans and non-binary people in the UK

Research using clinical samples with matched controls demonstrate higher levels of self-harm (Davey, Arcelus et al. 2016), eating disorders (Witcomb, Bouman et al. 2015), depression and anxiety (Bouman, Claes et al. 2017, Witcomb, Bouman et al. 2018) in the trans respondents than the matched controls. Key UK data came from a convenience sample study carried out by Scottish Transgender Alliance (McNeil, Bailey et al. 2012)

Key data (McNeil et al 2012) in summary: Self selected sample

  • 88% of 889 respondents had experienced depression
  • 84% of respondents had experienced suicidal ideation
  • 75% had experienced anxiety
  • 53% had self-harmed
  • 35% had attempted suicide

 

2.5 Gender identity services and mental health

Long waiting times in first referral to Gender Identity Clinics adversely affect the mental health of trans people (Hudson-Sharp and Metcalf 2016). Depression found to be 4 times higher in trans people waiting to access gender identity services, (Witcomb, Bouman et al. 2018). Suicidality (ideation and attempts) has been shown to be particularly high in trans people (McNeil, Bailey et al. 2012) and reduced by timely treatment by gender identity services (for those seeking it) (Bailey, Ellis et al. 2014).

 

2.6 Mental health service use

We know that LGB people seek to and/or access mental health services more frequently than heterosexuals (King, Semlyen et al. 2007, Chakraborty, McManus et al. 2011).

Mental health services were accessed by 24% of the 108,000 respondents to the UK Government’s LGBT survey (Government Equalities Office 2018). Whilst not offering comparative data, and reflecting a self-selecting sample, this is a large proportion of survey respondents. A further 8% made unsuccessful attempts to access services. Almost three quarters of these found access difficult with half suggesting they had to wait too long.

A systematic review by (King, Semlyen et al. 2007) demonstrated a number of difficulties experienced by LGBT with therapeutic provision including: concerns about safety, therapists making heterosexual (heteronormative) assumptions and misattribution of problem to LGBT identity.

LGBT individuals in the review also demonstrated concerns about therapist knowledge of LGBT lives and expressed preferences for a LGBT therapist (King, Semlyen et al. 2007).

Evidence shows that for some, health care professionals conflate LGBT identity with mental health such that for some LGBT people their identity is seen as a symptom or cause of their mental health condition (Drinkwater and Semlyen 2012, Ellis, Bailey et al. 2015).

  1. Physical health disparities for LGBT

3.1 Substance misuse disparities for LGB in the UK across lifespan – alcohol and tobacco

Evidence shows increased alcohol misuse in LGB population (Hagger-Johnson, Taibjee et al. 2013, Mercer, Prah et al. 2016).   From a representative sample, young LGB people (age 18/19) were twice as likely to use alcohol hazardously than heterosexuals (Hagger-Johnson, Taibjee et al. 2013).

  • LGB 2 x likely to have a history of cigarette smoking than those reporting a heterosexual identity at age 18/19 years

Using representative data, smoking is higher in LGB population (Hagger-Johnson, Taibjee et al. 2013, Shahab, Brown et al. 2017). Younger lesbians and gay men are more likely to smoke than heterosexual youth (18/19) (Hagger-Johnson, Taibjee et al. 2013).

  • LG nearly twice as likely to report drinking alcohol more than twice per week, and more likely to report binge drinking more often than weekly

Body Mass Index (Semlyen, Curtis et al. in press)

  • Lesbian women at increased risk of overweight/obesity
  • Gay men at increased risk of underweight

 

  1. Risk and protective factors for mental health in LGBT

Evidence of causal pathways to poorer mental health is lacking but links between mental health and health behaviour (Pesola, Shelton et al. 2014) and evidence of impact of discrimination on poorer mental health (Chakraborty, McManus et al. 2011, Woodhead, Gazard et al. 2016) indicate likely links lie within social determinants and structural inequalities.

LGBT mental health is impacted by structural inequalities experienced across a wide range of contexts including education (school and university), home and family, and health services (primary and secondary care).

 

  1. Research methodology in LGBT health and social care
  • The majority of studies in the UK examining LGBT health and social care use non-probability sampling (where respondents self-select to take part), or use opportunistic sampling (where respondents attending an event are invited to take part e.g. attendees at pride), or use clinical samples (where respondents are a particular group attending a particular health service for example attendees at gender identity services).
  • These data, while indicative, offer limited generalisability beyond the study/survey sample. It is important to distinguish between different types of evidence.
  • Studies that use representative data allow generalizability of the findings from the study to the wider population.

 

  1. Recommendations
  • Make every attempt to capture accurate LGBT+ population size by including SO and GI questions in the 2021 Census.
  • Suggest campaign to encourage LGBT people to feel safe and comfortable to disclose identity in Census 2021.
  • Suggest options for collecting Census 2021 data including internet access.
  • Increase LGBT+ health evidence base – quality (datasets that are representative), research on trans and non binary populations, greater research on intersectionality in LGBT+
  • Training for health care professionals and teaching for students on LGBT health should not be optional or tokenistic but be embedded and
  • Addressing homophobic, biphobic and transphobic bullying in educational and workplace settings and wider society. We know bullying linked to poor mental health.
  • Develop interventions to address discrimination, increase resilience and reduce impact on LGBT+ through targeted funding and resourcing.
  • Draw on LGBT people’s own expertise in developing policy and practice interventions.
  • Adopt best practice of existing LGBT community led services. The Government’s National LGBT survey highlighted that respondents found LGBT-specific charities particularly helpful when seeking support.
  • Routine inclusion of sexual orientation and gender identity in data collection.
  • Mandatory monitoring of sexual orientation and gender identity data across health and social care settings. Recording of sexual orientation identity is necessary to comply with Equalities Act, 2010.

 

  1. Recommendations for the National Adviser for LGBT healthcare:
  • There is a significant gap in scientific evidence on LGBT health, healthcare and its implementation. The Adviser should be someone who has direct experience of gathering and applying research evidence to enable them to work with relevant agencies to get this into practice.
  • Prorities should be improving access, quality and outcomes for LGBT people through:
    • Getting existing evidence into practice
    • Creating an advisory group who will produce policy guidelines and practice guidelines endorsed by ministers
    • Creating standards for better healthcare for LGBT people and advice and guidance on how to achieve this.

Date of submission: October 5th 2018

 

References

Bailey, L., S. J. Ellis and J. McNeil (2014). “Suicide risk in the UK trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt.” Mental Health Review Journal 19(4): 209-220.

Bouman, W. P., L. Claes, N. Brewin, J. R. Crawford, N. Millet, F. Fernandez-Aranda and J. Arcelus (2017). “Transgender and anxiety: A comparative study between transgender people and the general population.” International Journal of Transgenderism 18(1): 16-26.

Calzo, J. P., S. B. Austin and N. Micali (2018). “Sexual orientation disparities in eating disorder symptoms among adolescent boys and girls in the UK.” European child & adolescent psychiatry: 1-8.

Chakraborty, A., S. McManus, T. Brugha, P. Bebbington and M. King (2011). “Mental health of the non-heterosexual population of England.” British Journal of Psychiatry 198(2): 143-148.

Davey, A., J. Arcelus, C. Meyer and W. P. Bouman (2016). “Self‐injury among trans individuals and matched controls: prevalence and associated factors.” Health & social care in the community 24(4): 485-494.

Drinkwater, D. and J. Semlyen (2012). Why sexuality and gender identity matter: A discourse analysis of LGBT mental health services user’s talk of recovery. Qualitative Methods in Mental Health. University of Nottingham.

Elliott, M. N., D. E. Kanouse, Q. Burkhart, G. A. Abel, G. Lyratzopoulos, M. K. Beckett, M. A. Schuster and M. Roland (2015). “Sexual minorities in England have poorer health and worse health care experiences: a national survey.” Journal of General Internal Medicine 30(1): 9-16.

Ellis, S. J., L. Bailey and J. McNeil (2015). “Trans people’s experiences of mental health and gender identity services: A UK study.” Journal of Gay & Lesbian Mental Health 19(1): 4-20.

Ellison, G. and B. Gunstone (2009). Sexual orientation explored: A study of identity, attraction, behaviour and attitudes in 2009, Equality and Human Rights Commission Manchester.

Geary, R. S., C. Tanton, B. Erens, S. Clifton, P. Prah, K. Wellings, K. R. Mitchell, J. Datta, K. Gravningen, E. Fuller, A. M. Johnson, P. Sonnenberg and C. H. Mercer (2018). “Sexual identity, attraction and behaviour in Britain: The implications of using different dimensions of sexual orientation to estimate the size of sexual minority populations and inform public health interventions.” PLoS One 13(1): e0189607.

Government Equalities Office (2018). National LGBT Survey: Research Report.

Hagger-Johnson, G., R. Taibjee, J. Semlyen, I. Fitchie, J. Fish, C. Meads and J. Varney (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 3(8).

Hudson-Sharp, N. and H. Metcalf (2016). “Inequality among lesbian, gay bisexual and transgender groups in the UK: a review of evidence.” National Institute for Economic and Social Research.

Johnson, A., C. Mercer, B. Erens, A. Copas, S. McManus, K. Wellings, K. Fenton, C. Korovessis, W. Macdowall, K. Nanchahal, S. Purdon and J. Field (2001). “Sexual behaviour in Britain: partnerships, practices, and HIV risk behaviours.” The Lancet 358(9296): 1835-1842.

Jones, A., E. Robinson, O. Oginni, Q. Rahman and K. A. Rimes (2017). “Anxiety disorders, gender nonconformity, bullying and self‐esteem in sexual minority adolescents: prospective birth cohort study.” Journal of Child Psychology and Psychiatry 58(11): 1201-1209.

King, M., J. Semlyen, H. Killaspy, I. Nazareth and D. Osborn (2007). “A systematic review of research on counselling and psychotherapy for lesbian, gay, bisexual & transgender people.” British Association for Counselling and Psychotherapy.

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

McNamee, H., K. Lloyd and D. Schubotz (2008). “Same sex attraction, homophobic bullying and mental health of young people in Northern Ireland.” Journal of Youth Studies 11(1): 33-46.

McNeil, J., L. Bailey, S. Ellis, J. Morton and M. Regan (2012). Trans mental health and emotional wellbeing study, Scottish Transgender Alliance, Edinburgh.

Mercer, C. H., P. Prah, N. Field, C. Tanton, W. Macdowall, S. Clifton, G. Hughes, A. Nardone, K. Wellings and A. M. Johnson (2016). “The health and well-being of men who have sex with men (MSM) in Britain: Evidence from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).” BMC Public Health 16(1): 525.

Mercer, C. H., P. Prah, N. Field, C. Tanton, W. Macdowall, S. Clifton, G. Hughes, A. Nardone, K. Wellings, A. M. Johnson and P. Sonnenberg (2016). “The health and well-being of men who have sex with men (MSM) in Britain: Evidence from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).” BMC Public Health 16: 525.

Pesola, F., K. H. Shelton and M. B. van den Bree (2014). “Sexual orientation and alcohol problem use among UK adolescents: an indirect link through depressed mood.” Addiction 109(7): 1072-1080.

Semlyen, J., T. Curtis and J. Varney (in press). “Sexual orientation identity in relation to unhealthy Body Mass Index (BMI): Individual Participant Meta-Analysis of 93,429 individuals from 12 surveys.” Journal of Public Health.

Semlyen, J., M. King, J. Varney and G. Hagger-Johnson (2016). “Sexual orientation and symptoms of common mental disorder or low wellbeing: combined meta-analysis of 12 UK population health surveys.” BMC Psychiatry 16(1): 67.

Shahab, L., J. Brown, G. Hagger-Johnson, S. Michie, J. Semlyen, R. West and C. Meads (2017). “Sexual orientation identity and tobacco and hazardous alcohol use: findings from a cross-sectional English population survey.” BMJ open 7(10): e015058.

Witcomb, G. L., W. P. Bouman, N. Brewin, C. Richards, F. Fernandez‐Aranda and J. Arcelus (2015). “Body image dissatisfaction and eating‐related psychopathology in trans individuals: A matched control study.” European Eating Disorders Review 23(4): 287-293.

Witcomb, G. L., W. P. Bouman, L. Claes, N. Brewin, J. R. Crawford and J. Arcelus (2018). “Levels of depression in transgender people and its predictors: Results of a large matched control study with transgender people accessing clinical services.” Journal of affective disorders 235: 308-315.

Woodhead, C., B. Gazard, M. Hotopf, Q. Rahman, K. Rimes and S. Hatch (2016). “Mental health among UK inner city non-heterosexuals: the role of risk factors, protective factors and place.” Epidemiology and psychiatric sciences 25(5): 450-461.

Notes

[1] Researchgate link in introduction contains full text for most papers cited in this document. https://www.researchgate.net/profile/Joanna_Semlyen

[2] This report will use the acronym LGBT in reference to the lesbian, gay, bisexual and trans population but some data presented may also include non-binary or other identities. On occasion where data is specific to one group, set or subset of identities, different acronyms will be used and each will be clarified.

[3] https://www.ons.gov.uk/methodology/classificationsandstandards/sexualidentityguidanceandprojectdocumentation

[4] https://www.ons.gov.uk/methodology/classificationsandstandards/measuringequality/genderidentity

[5] The ONS question asks ‘Which of the following options best describes how you think of yourself?’

Response options were ‘Heterosexual or Straight’, ‘Gay or Lesbian’, ‘Bisexual’, ‘Other’, or refusal https://www.ons.gov.uk/methodology/classificationsandstandards/sexualidentityguidanceandprojectdocumentation

The inclusion of ‘other’ as a distinct group is an important issue. Research by the author found that people who identify as ‘other’ show poorer mental health in line with levels demonstrated by lesbian, gay and bisexual population. See Semlyen, J., M. King, J. Varney and G. Hagger-Johnson (2016). “Sexual orientation and symptoms of common mental disorder or low wellbeing: combined meta-analysis of 12 UK population health surveys.” BMC Psychiatry 16(1): 67.

[6] http://www.equalityhumanrights.com/sites/default/files/documents/technical_note_final.pdf

[7] (Semlyen et al, for University of Leicester commissioned by Nottingham CCG, as yet unpublished)

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