Lesbian, Gay, Bisexual, and Trans (LGBT) people

Lesbian, Gay, Bisexual and Trans (LGBT) people

Introduction

 

Terminology:

 

  • Bisexual: someone who is attracted to people of the same gender and/or opposite gender
  • Gay: a man or woman who is attracted to people of the same gender
  • Heterosexual/straight: someone who is attracted to people of the opposite gender
  • Lesbian: a woman who is attracted to other women
  • Trans: someone whose assigned sex at birth differs to their psychological gender
  • MSM: Men who have Sex with Men – a term used to describe the sexual behaviour of this subset of men rather than their self-identified sexual orientations, which may be markedly different from each other
  • Sexual orientation: the general attraction a person feels towards one sex or another (or both)
  • Gender identity: whether an individual feels comfortable in the gender that they were assigned at birth
  • The term LGBT stands for: lesbian, gay, bisexual, and transgender - although we consider LGBT together, we need to remember that there are two minority groups covered by this term both of which are protected by law: LGB people who have a minority sexual orientation and trans people who have a minority gender identity (their assigned sex at birth conflicts with their psychological gender) - different legal frameworks apply to LGB people and trans people and there will be differences in how to promote equality within both groups

This section of the Joint Strategic Needs assessment (JSNA) aims to map the needs of LGBT people in Wokingham as part of a formal process for the first time. It is acknowledged that the quality of evidence used is variable. However, this is an important first step in recognising the needs of this group which include the need for further data collection, analysis and use.

 

When we consider the needs and experiences of healthcare of LGBT people, it is important not to view LGBT as a singular group but rather as a group of individuals with individual differences. These are individuals who will identify with many different groups of which just two are based on sexual orientation and gender identity. The situations in which they choose to disclose these identities may differ and this disclosure may be given in different forms.

 

In light of the fact that people identify with many different groups we also need to also consider that within the LGBT population there will be further minorities amongst this group. For, example LGBT people who are also disabled or also from a Black or Minority Ethnic Background. These minorities within minorities are discussed throughout.

 

Why we need a specific focus on the people who are LGBT in our JSNA

 

It has been clearly demonstrated that commissioners and providers of health and social care services fail to recognise LGBT communities which serves as a barrier to service access (Williams, Varney, Taylor, Fish, Durr, & Elan-Cane, 2013).

 

Many Joint Strategic Needs Assessments (JSNAs) currently do not address LGBT issues and experiences of healthcare and these remain a low priority for policy makers and commissioners. This is despite the fact that they have a statutory obligation to do so and that key public health issues disproportionately effect LGBT populations as will be described below (The Lesbian & Gay Foundation, 2012). If we are to address inequalities in our JSNA then we need to give attention to the LGBT population. There is need to ensure that there is information specific to the needs LGBT people and that evidence about the general population is linked to evidence about LGBT people. Therefore, readers are encouraged to read this section of the JSNA in the context of its whole. Links to topics felt to be of particular relevance are provided at the bottom of the page.

There is no robust evidence that will tell us how many LGBT people there are in the population although we can use what evidence we have to make some estimates and these are described below. A key theme throughout this assessment is the lack of high quality, large scale research around the needs of LGBT people. However, what is included in the sections below is based on the evidence that we do have and clearly indicates numerous inequalities in the health and wellbeing of LGBT people compared to the general population as well as inequalities in health and social care service access and provision. Therefore, the main focus of the following section of this assessment will focus on the known and indicated inequalities experienced by LGBT people both as a group as a whole and separately for groups within the LGBT population.

Estimates of the number of LGBT people within the population

 

  • The “I exist” survey respondent characteristics (sample = 2,580)

  • 41% had a religion or belief 6% of whom said they were Christian

  • 68% were in employment (similar to general population)

  • 1/10 identified as carers (similar to general population

  • 42% said they had realised that they might be LGB between the ages of 13-15

  • Only 14% had come out by this age

  • By 25 years old 25% had not come out

  • 3% have never come out (The Lesbian and Gay Foundation, 2012a)


Sexual orientation is not asked on the National Census and is not monitored for consistently in employment or services. Research allowing us to make a reasonably reliable estimate indicates that 5-7% of people are LGB (LGBT Foundation). There will be variation between different areas with sexual minorities more likely to migrate to larger cities.


An estimated 1% of the population identify with a gender that is not the same as the sex that they were born with. 0.2% may seek gender reassignment intervention with the median age for presentation for reassignment being 42 years of age. There are now an increasing number of people presenting in adolescence (Varney, 2013).

Key health issues and inequalities for all LGBT people


Qualitative evidence coming from the LGBT community and peer reviewed research both provide a wealth of evidence of the health inequalities faced by LGBT people. Key areas where inequalities are described are; lifestyle behaviours (e.g. smoking and drug use), sexual health, mental health, workplace health, and service access and quality. Lifestyle, sexual health, and mental health inequalities are discussed in more detail later in this assessment. The experiences reported by LGBT people in relation to workplace health and services access are outlined in the table below.
 

Experiences of LGBT people relating to healthcare and workplace health
Experiences of LGBT people relating to healthcare and workplace health

Research shows that; patients want to talk to healthcare professionals about their sexual orientation; patients want the healthcare professional to initiate these conversations; but clinicians feel uncomfortable discussing issues around sexual orientation due to different reasons such as a lack of confidence of dealing with sexual health, having fears of offending the patients and a lack of understanding of new sexual terminology (Rogers, 2014).


The Public Health Outcomes Framework Companion Document (Williams, Varney, Taylor, Fish, Durr, & Elan-Cane, 2013); describes the health inequalities experience by LGBT people across each Public Health Outcomes Framework (PHOF) indicator. These inequalities flow through all domains of the framework beginning with the wider factors which are known to lead to inequalities in health. These stem from discrimination which impact on housing provision, education, and experiences of crime and violence. There is much evidence that shows that LGBT people are more likely to engage in lifestyle behaviours that are damaging to health including smoking, alcohol misuse, and drug use. They are less likely to engage with health improvement services which support people to improve their own health as well as to engage with screening services such as cancer screening. LGBT people are more likely to experience inequality in relation to healthcare services and are more likely to die prematurely.


The Adult Social Care Outcomes Framework Companion Document (The National LGB&T Partnership, 2015) brings together existing evidence on the needs of LGBT people in a similar way to the Public Health Outcomes document but, this time, with a focus on care and support needs. Providers of social care services have commented that sexual orientation and gender identity were never mentioned in regards of the provision of services.
There is evidence that inequalities exist between LGBT people and the general population against the majority of the indicators within these two frameworks and these are included in the additional information provided along with this assessment.


Key health issues and inequalities for lesbian women


It should not be assumed that all issues around the health of lesbian women are the same as those of heterosexual women with recent research suggesting some key differences. Research indicates that lesbian women do not seek intervention or support from the health sector and that they are less likely to respond to preventative healthcare messages (The Department of Health, 2009). The table below outlines some of the key health inequalities for these women.

Key inequalities for lesbian women
Key inequalities for lesbian women

With regards to the sexual health of lesbian women, there is a common assumption that lesbian women cannot contract STIs or are at a lower risk than heterosexual women. This is partly based on the underlying assumption that lesbian women have never had sex with men. However, one study showed that 85% of lesbian women had previously had sex with men. It is, therefore, important to note that a lesbian identity does not necessarily reflect a lifetime of same-sex relationships. Furthermore, some STIs have been diagnosed with women who have had no sexual history with men including genital herpes and warts (The Department of Health, 2007i).


Key health issues and inequalities for gay men

Suicide and HIV infection are both key health concerns for gay men. However, we need to be mindful that gay men have other health needs other than those that relate to sexual activity and HIV prevention in order not to perpetuate the belief that gay men’s health needs relate to what they do rather than who they are (The Department of Health, 2009).  Key health inequalities relating to gay men are outlined in the table below.

Key inequalities for gay men
Key inequalities for gay men

Gay men have been criticised for taking unnecessary sexual risk based on the data around HIV infection below:

  • 80% of new domestic HIV infections are among MSM
  • 59% of people living with AIDs are gay and bisexual men
  • 66% of gay men do not discuss safer sex with their GP
  • Up to 50% of gay men have never been tested for HIV
  • 1 in 10 MSM are living with HIV (The Lesbian & Gay Foundation, 2012)

We need to remain mindful to the fact that some gay men are very responsive to safer sex promotion with condoms been widely and properly used. The high rate of infection that we see despite this relates to a complex relationship between a previous lack of information, patterns of sexual activity, and the risk of infection and existing prevalence of the virus amongst gay men (The Department of Health, 2009).


Key health issues and inequalities for bisexual men and women


Bisexual people’s health needs may differ from lesbian womens, gay men’s, and heterosexual people’s health.  The evidence that is available suggests that bisexual people are at a increased risk of eating disorder, mental ill health including anxiety and depression and suicide, and increased alcohol consumption. Bisexual women are more likely to be tested for STIs than lesbian women. However, fewer bisexual men have ever been for an STI or HIV test than gay men (Williams, Varney, Taylor, Fish, Durr, & Elan-Cane, 2013). There is evidence that bisexual men are less well educated about STIs, are much less likely to see materials aimed at gay men, are more likely to have trouble obtaining and using condoms, and have had unsafe sex with a greater number of men than exclusively gay men (The Department of Health, 2007m).

Results of the Stonewall survey related to the bisexual cohort of responders are described below:

Health and wellbeing of bisexual men and women
Health and wellbeing of bisexual men and women

Key health issues and inequalities for trans people


Amongst the LGBT population as a whole, the research into trans health is particularly limited (outside of the gender reassignment pathway of care). However available evidence suggests that this is a group that are potentially of a high vulnerability  to poor mental and physical health outcomes and poor service provision.


Trans people (particularly male to female trans women) are often the victims of violence. More than 1/3 of trans people have attempted suicide. They are 25 times more likely to attempt suicide that then general population. Young trans people report poor housing, financial difficulties, access to healthcare, a lack of family support, higher rates of substance abuse, and high risk sexual behaviours as particular concerns (The Department of Health, 2007j).
The largest survey of Trans people’s mental health in Europe was conducted in 2013.

Despite significant improvement in the clinical support offered to trans individuals, gender reassignment care pathways are inconsistent with 25% refused treatment because a practitioner did not approve of gender re-assignment  (The Lesbian & Gay Foundation, 2012). 29% of trans people reported that being trans adversely affected the way that they were treated by healthcare professionals (The Department of Health, 2007j).

There are many examples of inappropriate healthcare been provided to trans people including;

  • Female to male trans men rarely including in breast screening

  • Male to female trans women rarely offered prostate screening

  • Placing trans women on male wards and trans men on female wards

More than 30% of trans people in one study experienced discrimination when they were:

  • Trying to get information from their GP

  • Obtaining funding for gender reassignment surgeries

  • Accessing ordinary non-trans healthcare

Trans people also report problems with healthcare professionals:

  • Persisting in using male rather than female pronouns and vice versa

  • Being critical about appearance

  • Asking for their ‘real’ name (The Department of Health, 2007j)


Key health issues and inequalities for young LGBT people

It is widely recognised that being a young person in itself presents many challenges particularly when transitioning from childhood to adulthood. Being a young person who is in a minority group can lead to extra vulnerabilities to negative experiences and resulting poor mental and physical wellbeing.

 

However one difficulty for people responsible for supporting children and young people is that not all young LGBT will be open about their sexuality and gender identity for many years after they become aware of it themselves. Many young people know their sexual orientation by the age of 11 or 12 but may not tell anyone until years later and just 13% of young people have disclosed their sexual orientation to a healthcare provider (The Department of Health, 2007l) Stonewall, 2015 found the below:96% of gay young people say that they hear homophobic remarks made by other children in schools (17% say they have heard teachers make homophobic remarks) .


84% of gay young people feel distressed when the word ‘gay’ is used as an insult (45% feel very distressed) .


2/3 of secondary school and 2/5 primary school staff admit they do not always intervene when they hear derogatory language.

 

Half of secondary and quarter of primary school teachers think homophobic language is ‘just harmless banter’ .

 

94% of teachers have not received specific training on how o deal with homophobic bullying and language.

 

Homophobic bullying is higher is schools where teachers never challenge homophobic remarks compared to schools where homophobic remarks are always challenged.


The table below summarises some of the key health inequalities between young LGBT people and their peers:

Health inequalities for young LGBT people
Health inequalities for young LGBT people

Key health issues and inequalities for older LGBT people


Although older LGBT people’s health and care needs are mostly likely to be similar to that of the wider older person population, the lack of recognition of this group when it comes to service commissioning and provision likely leads to overlooked needs specific to this group (The Department of Health, 2007h).


LGBT older people are more likely to live alone and have fewer support networks than the general older person population (The Lesbian & Gay Foundation, 2012). They are twice as likely to be single and four and a half times less likely to have children to call upon in times of need (The Department of Health, 2007h).

Older LGBT people have extra concerns around entering residential accommodation due to isolation and discrimination and the need, therefore, the hide their sexual orientation.

Many health and social care providers report not having worked with older LGBT people. However, only 14% of LGBT people are open about their sexuality with providers of services. Just 25% of older LGBT people believe that health professionals were positive towards LGBT people and only 16% thought health professionals would be knowledgeable about LGBT lifestyles (The Department of Health, 2007h).

 

Key health issues and inequalities for LGBT people with disabilities

There is numerous literature which highlights the challenges for people with disabilities in being able to express their sexuality and being supported in developing a sexual identity (Varney, 2013).


Although the evidence with regards to disability in the LGBT community is limited, some evidence suggests that; disability in the trans community is higher than the general population; higher disability prevalence in the LGBT community in general (15-17%); 23% of older LGBT people have a disability which limits their daily activity in some way (Varney, 2013).

Compared to heterosexual disabled people, fewer LGBT disabled people are accessing the health and social care services that they feel they need. Smoking and drug use is higher amongst disabled gay and bisexual men than it is amongst non-disabled gay and bisexual men. Fewer LGBT disabled people have disclosed their sexual orientation/gender identify to their GP than non-disabled LGBT people (Williams, Varney, Taylor, Fish, Durr, & Elan-Cane, 2013).

A number of small scale qualitative studies suggest the following as particular issues for disabled LGBT people:

  • Difficulties in meeting other LGBT people
  • Lack of validation for same-sex relationships
  • Lack of acknowledgement of LGBT people
  • Lack of acceptance in the non-disabled LGBT community
  • Lack of privacy
  • Few policies mean that staff do not feel supported to do proactive work

Key health issues and inequalities for BME LGBT people

There is variation between different ethnic groups of LGBT people in health risks and behaviours. BME LGBT people have higher smoking rates than heterosexual BME individuals. BME lesbian and bisexual women have higher risk of cardiovascular disease and cancer compared to both white lesbian and bisexual females and heterosexual BME women (Williams, Varney, Taylor, Fish, Durr, & Elan-Cane, 2013).

 

BME LGBT health needs have almost been completely overlooked in research conducted in the UK. Gay African-Caribbean men in the UK are twice as likely to be living with HIV than White gay men. US research suggests that BME lesbian and bisexual women are more likely to be overweight compared to their heterosexual peers. BME LGBT communities are disporportionately affected by violence, abuse and harassment. African-Caribbean men in general are more likely to receive a diagnosis of schizophrenia and are three time more likely to be sectioned under the mental health act (The Department of Health, 2007f). There is some evidence that BME gay men who have a HIV diagnosis are more prone to psychological stress than their Caucasian counter parts. BME LGBT people are also more more likely to experience physical abuse and harassment from strangers than White LGBT people (Varney, 2013).

 

UK research has highlighted that migrant gay men are particularly vulnerable and have a higher risk of poor mental health and sexual risk behaviours (Varney, 2013).

Key health issues and inequalities for LGBT people from faith communities

Over a third of LGBT people identify with a faith or belief and different religions take different attitudes towards sexual orientation and gender identity. These can range from complete acceptance complete condemnation. Research had highlight both the tensions that can occur as a result of religious emphasis on traditional gender roles and the positive support coming from faith-based voluntary and community groups to enable people to explore their identity (Varney, 2013).

Recognition

There is a need to undertake awareness raising of LGBT needs for both service providers and commissioners of services. This should include regular training for healthcare staff on how to work with trans patients on issues of dignity, particularly the right to be treated as a member of their new gender, and privacy needs.

 

Regular and detailed local assessments of LGBT people should be undertaken and these should focus on the different groups within the LGBT population. There is a particular need for an individual assessment of the trans population needs and the needs of BME LGBT people.

 

Images of LGBT people and their families should be included in promotional materials and LGBT-friendly polices should be clearly displayed.

Health and Wellbeing Board partners should ensure that single equality schemes explicitly consider sexual orientation and gender identity.

 

Local strategies and action plans should consider the needs of LGBT people. These include older people, drug and alcohol, mental wellbeing and crime and disorder strategies and action plans.

 

Engagement

The commissioning and provision of services should be done in partnership with LGBT voluntary and community sector groups and service specifications should explicitly consider the needs of LGBT people. These specifications could refer to and relate to Stonewall’s Healthcare Equality Index.

 

Consult with LGBT staff about the obstacles that they come across in accessing health and social care services.

 

Ask LGBT staff about collecting data and how they think it should be done.

Community Sport and Physical Activity Networks should explicitly consider the needs of LGBT groups in developing local engagement strategies.

 

Local government and NHSE should work together to promote chlamydia screening uptake amongst LGBT people and require service providers to monitor sexual orientation and gender identity.

 

Monitoring

  • Steps should be taken to ensure representation of LGBT people in smoking surveillance to understand smoking rates in this group
  • Local government homelessness and housing strategies should consider the needs of LGBT service users and monitor sexual orientation and gender identity in service user datasets
  • Coroners and medical examiners should monitor sexual orientation and gender identity and explore a potential link between suicide and sexual orientation and gender identity
  • Commissioners should include a requirement in contracts for service providers to monitor sexual orientation and gender identity - this should be used to better understand and meet LGBT service users’ needs

Service provision

Health improvement services should deliver targeted messages to LGBT people which have been shown to be cost effective.  In particular, drug and alcohol and smoking prevention and cessation interventions should be targeted at LGBT people.

 

Services for gay men with eating disorders need to address their particular concerns: it should not be assumed that these are the same as heterosexual men or women.

 

Physical examinations of trans people should be offered to patients on the basis of the organs present rather than the perceived gender.

 

Lesbian women should be offered STI and cervical cancer screening in a manner consistent with that of heterosexual women.

 

Services should be encouraged to take part in the Stonewall Workplace Equality Index.

 

Steps should be taken to ensure that schools are following Stonewall’s guidance on tackling homophobic language within schools.

 

Schools should ensure that PHSE includes positive and supportive discussion about sexual orientation and safe sex.

 

School nurses should be trained to support LGBT youth and young people questioning their sexual orientation or gender identity.

 

Service commissioners and providers should ensure staff receive training on LGBT issues; have promotional materials using LGBT language and imagery; monitor service user sexual orientation and gender identity and data use to improve services.

 

Health and social care professionals should establish a local database of LGBT community groups for signposting.

 

CCGS should consider the needs of LGBT communities when commissioning secondary prevention such as cardiac rehabilitation.

 

LAs should provide care services with recourses and signposting information to enable carers to have knowledge and information about appropriate and specific community resources.

 

Social care providers should ensure that’s staff receive training on LGBT issues and are able to discuss an individual’s needs sensitively so the impact of person-centred and personalised care can be assessed and responded to.