In a recent blog, I reflected on the impact of COVID-19 on a very different pride this year as well as the progress we still need to make on supporting our LGBTQ+ community in regard to health.
I talked about the widespread discrimination that still exists in our healthcare system, with 70 per cent of LGBTQ+ doctors reporting one or more types of harassment due to their sexuality* and the need for interventions such as ‘Freedom to Speak Up Guardians’ to tackle this behaviour.
I also more briefly touched upon the ongoing need to discuss and raise awareness of the health issues and inequalities facing the community throughout medical education and training. As pride month draws to a close, I felt it would be good to expand on this point drawing on the key reviews**.
Notably, there is a marked lack of high certainty evidence on LGBTQ+ health and a particular lack of research on the health of lesbian and bisexual women as well as transexual people.
As we move forward, it is vital that research in this area is specifically commissioned, more data on sexuality and gender identity is collected and specific policies developed. However, there is at least moderate certainty evidence available for certain inequalities.
Firstly, LGBTQ+ people tend to have worse mental health than the general population with roughly one and a half times the risk of depression and anxiety and twice the risk of suicide.
These are particularly associated with experiencing homophobic discrimination and isolation from family and origin community whilst being connected to an LGBTQ+ community is protective.
Evidence is less certain for transgender people, but even higher levels of anxiety, depression and suicide risk are typically found especially when referral to gender identity services is delayed (only 60% of adult patients are seen within a year) or refused or discrimination encountered.
Psychiatric care has also been found to be problematic with gender identity pathologised and mental health issues being inappropriately attributed to transexual status.
Secondly, several behavioural risk factors are more prevalent in LGBTQ+ people compared to the general population, notably binge drinking, smoking, and substance abuse.
Smoking and hazardous drinking are particularly prevalent amongst younger gay/bisexual men (at more than double the general population level) whilst the drug use tends to be methamphetamine based and concentrated amongst middle-aged gay/bisexual men.
Qualitative research** suggests that these behaviours may be partly due to coping strategies for mental health problems and discrimination as well as due to peer pressures arising from the LGBTQ+ nightlife scene. Again, less information is available for transgender people, but alcohol and substance misuse are thought to be more prevalent.
Finally, LGBTQ+ people tend to experience worse healthcare and health education with higher levels of dissatisfaction with primary care than the general population and a third of patients having experienced discrimination when accessing healthcare within the last year. Presumption of cis-gender and/or heterosexuality is a leading cause for this as well as failing to recognise specific needs and not acknowledging partners.
Specific LGBTQ+ concerns also include poor sexual fulfilment support for gay/bisexual men, poor information on and worse uptake of sexual health and cervical cancer screening for lesbian/bisexual women, as well as inappropriate follow-up and screening care for trans-people following transition. The latter can include examples such as trans-men no longer being offered breast/cervical screening.
These examples are by no means exhaustive and there may well be inequalities that we are simply not aware of given the ongoing lack of research in this area. However, as this Pride month ends, I hope that these insights help to draw attention to the progress we still need to make.
Daniel Jones is a public health registrar in Wales.