Below the radar

It is well known that people from the LGBTQ+ community experience health inequalities and difficulties with accessing healthcare, but how these can be addressed is less clear. Of deep concern is the amount of data that has not yet been collected – and the implications of this are considerable. Yet there are ways we can alleviate these health inequalities.

Sexual minority people – individuals who identify as gay, lesbian, or bisexual, and those who are attracted to or have sexual contact with people of the same gender – and gender minority people – individuals whose gender identity (man, women, other) or expression (masculine, feminine, other) is different from their sex assigned at birth – face considerable health inequalities. These include worse levels of general health and wellbeing; higher rates of mental health difficulties, including anxiety, depression, suicide attempts, self-harm and eating disorders; higher rates of teenage pregnancies and asthma in sexual minority women; difficulties with accessing health services in both sexual minority women, such as far fewer having cervical smears, yet higher rates of cervical intraepithelial neoplasia, and in trans men and women accessing routine healthcare; and higher rates of HIV in men who have sex with men and in trans women.

And what about the impact of Covid-19 on LGBTQ+ people? A recently published systematic review found no publications on the health of UK sexual and gender minority people during the pandemic, and there has been next to nothing published since. Even Sir Michael Marmot’s report – Build Back Fairer – has little mention of LGBTQ+ people. Instead, almost all the data about the impact of Covid-19 has come from LGBTQ+ charities and third sector organisations, in spite of many of them having considerable drops in income during the pandemic. Their research showed a worsening of mental health and wellbeing, health behaviours, safety, social connectedness and access to routine healthcare.

Why this is happening is largely unclear. There seems to be much work on individual drivers, for example minority stress theory, or the lasting impact on individuals of Section 28 of the Local Government Act. However, social drivers can also shape health outcomes. In the United States, research has shown that where some states have implemented more protective policies towards LGBTQ+ people than others, levels of mental health difficulties are lower. This shows that structural stigma and discrimination are associated with levels of psychiatric disorders, but are they causal? And in states where same sex marriages are banned, sexual minority adults experienced worsening levels of mood disorders, alcohol use disorders and generalised anxiety disorders compared to levels before the bans were introduced.

In the UK, what is noticeably missing from any of the research available is the lack of data on incidence, hospitalisations, and deaths from Covid-19 in LGBTQ+ people. My conversations with the Office for National Statistics (ONS) has indicated that they struggle to generate this data because none of the currently available datasets collect both sexual orientation and gender identity as well as Covid-19 outcomes. Supposedly, the reason for this is partly because this data was not collected in the 2011 census. However, the ONS validated a questionnaire measure of sexual orientation around 12 years ago, so any of the Covid-19 cohort studies set up at the start of the pandemic could have included sexual orientation, but did not.

The fact is that sexual and gender minority people remain largely invisible within the NHS. For example, the Sexual Orientation Monitoring Standard has not been implemented sufficiently to generate useable data. The National Disease Registration Service (NDRS) added sexual orientation to the core demographic set in 2018 as an optional field, and was due to become mandatory in 2020 but has been delayed due to the Covid-19 pandemic, and no data on sexual orientation and cancer has yet been published by them. They have yet to add gender identity.

It tends to be that, where there has been no data available, the assumption is that there are no differences between the minority and the majority regarding health and use of health services. So, when the current government minister for equalities, Kemi Badenoch MP, states that, “we have not found that LGBTQ+ groups specifically have been disproportionately affected [by Covid-19],” she has conflated a lack of data with the assumption of no effect. Badenoch has also stated that: “Government vigorously scrutinises research from a wide range of sources on the impact of Covid-19 on minority groups, including the LGBTQ+ population. We routinely monitor research by academics and other agencies published in this area.” It is a mystery as to which data she has scrutinised.

There are several reasons as to why Covid-19 may have adversely impacted LGBTQ+ people. In addition to the health inequalities mentioned above, many work in frontline health and care services, where Covid-19 exposure rates are much higher. And although educational attainment tends to be higher, income levels tend to be lower than the majority population. Rates of homelessness are also high amongst sexual and gender minority young people. If measured, Covid-19 rates may well be higher.

And when we live in a society where there are worsening health inequalities, coupled with more difficulties accessing services, costs to the public purse will inevitably be higher. As the Fabian Society’s Prescription for Fairness mentions: “People with serious mental health problems, for instance, have an employment rate of just 28 per cent and are more than 3.5 times more likely than others to be in problem debt.”

So what can be done to address health inequalities in sexual and gender minority people and prevent them from being under-investigated, and unreported?

The first step must be to acknowledge that institutional homophobia, biphobia and transphobia is a real problem in our society. This phenomenon can be described as the collective failure to provide appropriate and professional services to people because of their sexuality or gender identity. It can be detected in processes, attitudes and behaviour, which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and stereotyping. And it is resulting in LGBTQ+ groups being ignored.

Next, data should be collected on LGBTQ+ people routinely in all government-funded data collection projects, including funded research by arms’ length bodies such as the National Institute for Health Research and the Medical Research Council.  Since structural discrimination, such as US same-sex marriage bans, adversely impact mental health, government policies in the UK should make extra efforts not to have similar effects. To ensure this, equalities impact assessments should be carried out for suggested policies that might make life worse for sexual and gender minority people. Plus, training for health and care professionals must include sessions on all of the protected characteristics listed in the Equalities Act and other minority groups, rather than vague mentions of equality and diversity issues. This will mean that the people on the ground collecting the data will understand why it is so important.

LGBTQ+ people’s health has a long history where the assumption has been that there are no issues, because there is no data to show such issues. But, whenever data has become available, it has shown that there are considerable health inequalities. Ignoring these health inequalities will not make them go away, and societal approaches as well as individual action are needed to address them.

This piece forms part of our Prescription for Fairness blog series. Read the publication and take a look at the rest of the series.

Image credit: Weiran Zhang.