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LGBT+ Health inequalities: Research evidence

This session aims to highlight the specificity of LGBT+ health inequalities and present available evidence, discussing quality indicators and identifying gaps. Recommendations to reduce these inequalities will be provided.

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LGBT+ Health inequalities: Research evidence

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  1. LGBT+ Health inequalities: Research evidence Dr Joanna Semlyen J.Semlyen@uea.ac.uk @Dr_Jo_S #POSTlive

  2. Aims of session An understanding of the specificity of LGBT+ health inequalities Present available evidence of LGBT+ health inequalities (with an understanding of what quality evidence is and isn’t) highlighting obvious gaps Recommendations to reduce LGBT+ health inequalities Joanna Semlyen July 5 2018, POST

  3. Numbers of LGBT+ Estimates • A Government estimate of the size of the UK’s LGB population for the purposes of assessing the impact of Civil Partnerships in 2003 suggested 5-7% • Research by the Gender Identity Research and Education Society (GIRES) indicates a level of trans people in the population of around 0.5- 1% • Modelled estimate by Public Health England 2017. Based on all recorded responses to UK surveys - a range of between 0.9%-5.52% LGBO, present weighted estimate of 2.5% • Depends on • how asked (ftf, online, written) • how worded (attraction, behaviour, identity) Joanna Semlyen July 5 2018, POST

  4. Census 2021 Very real opportunity to establish size of LGBT+ population by inclusion of SOGI Qs Joanna Semlyen July 5 2018, POST

  5. LGBT+ health inequalities Growing up LGBT – in intolerant society How? Prejudice/ rejection – family, friends, teachers, employers – across lifespan Why? Attitudes of society – intolerance, disapproval, discrimination, actual homo/transphobia In health context. Attitudes of health professionals – homophobia, heterosexism and heteronormativity Exacerbated by Lifestyles – pub/club as unique safe space – due to social exclusion - yet these are centred around alcohol/drugs. Also coping mechanisms Reparative/conversion therapy Joanna Semlyen July 5 2018, POST

  6. Research evidence: UK 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 evidence base - few longitudinal cohort studies and population health cross sectional surveys – include the ONS* question on SO. No GI question ‘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 *Office of National Statistics, 2009 Joanna Semlyen July 5 2018, POST

  7. Study model: Mental health Physical health Sexual orientation identity Minority stress Health behaviours Mortality Mental health Joanna Semlyen July 5 2018, POST

  8. Systematic review: suicide, substance misuse, self harm and mental health • Meta analysis showed increased prevalence of mental health in LGB compared to heterosexual (King, Semlyen et al., 2008) • Suicide attempts lifetime OR x 2 (x 5 men) • Suicidal ideation lifetime OR x 2 • Alcohol dependence last 12 months OR x 1.5 (x 4 women) • Drug dependence last 12 months OR x 3 • Included studies were predominantly USA youth Joanna Semlyen July 5 2018, POST

  9. UK: SEXUAL ORIENTATION, COMMON MENTAL DISORDER AND LOW WELLBEING • Data pooling across 12 UK population health surveys • [British Cohort Study 2012, Health Survey for England 2011, 2012 and 2013, Scottish Health Survey 2008 to 2013, Longitudinal Study of Young People in England 2009/10 and Understanding Society 2011/12] • Individual participant meta-analysis was used to pool estimates from each study, allowing for between-study variation • Analytic sample - those surveys with available data on sexual orientation identity, mental health and covariates • 94,818 participants [1.1 % identified as lesbian/gay, 0.9 % as bisexual, 0.8 % as ‘other’ and 97.2 % as heterosexual] Joanna Semlyen July 5 2018, POST

  10. SEXUAL ORIENTATION, COMMON MENTAL DISORDER AND LOW WELLBEING Lesbian/Gay > mental health disorder than Heterosexual • under 35 (OR = 2.06, 95 % CI 1.60, 2.66) • non significant at age 35–54.9 (OR = 1.03, 95 % CI 0.71, 1.48) • strongest at age 55+ (OR = 2.11, 95 % CI 1.16, 3.83) Bisexual > mental health disorder than Heterosexuals (and LG). • under 35 age group (OR = 2.31, 95 % CI 1.83, 2.90) • age 35 to 54.9 (OR = 1.80, 95 % CI 1.29, 2.50) • strongest at age 55+ (2.45, 95 % CI 1.58, 3.79) Joanna Semlyen July 5 2018, POST

  11. Trans mental health • Very little data on trans health. • No UK population studies. • One survey study, by Scottish Transgender Alliance (Ellis, Bailey & McNeil, 2015) • 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 • Want gender identity data to be recorded in surveys to allow high quality evidence. Requires agreement over question(s) Joanna Semlyen July 5 2018, POST

  12. Study model: physical health Physical health Sexual orientation identity Minority stress Health behaviours Mortality Mental health Joanna Semlyen July 5 2018, POST

  13. UK DATA: SEXUAL ORIENTATION, Alcohol, smoking and BMI • Smoking and hazardous alcohol use (Hagger-Johnson G, Taibjee R, Semlyen J, 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 • 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 et al 2018 under review) • Lesbian women at increased risk of overweight/obesity • Gay men at increased risk of underweight Joanna Semlyen July 5 2018, POST

  14. LGBT+ health inequalities: evidence Summary • There is wide evidence that LGBT people experience both mental and physical health inequalities (King et al. 2008, Institute of Medicine 2011, Semlyen et al 2016, Semlyen et al 2018, Ellis et al 2015), due in part to increased health risk behaviours (Hagger-Johnson et al. 2013) • Known variation in NHS standards of care received by LGBT people (GMC Equality and Diversity Strategy, 2014-17, p. 7) • LGBT population avoid and delay in accessing healthcare and qualitative data shows experiences of heteronormative and homophobic health services care (Hulbert-Williams et al 2017, Semlyen and Flowers 2018) and transphobic health screening (Semlyen and Kogliovani 2017) • Lack of knowledge and understanding about LGBT+ health issues in health care professionals (King et al 2007, Semlyen 2015) Joanna Semlyen July 5 2018, POST

  15. Moving forwards…Need a complex systems approach Specific provision tailored to needs of LGBT+ people Mainstream systems mitigate for better LGBT+ health outcomes Both need to inform and be informed by each other Joanna Semlyen July 5 2018, POST

  16. |recommendations| • Interventions to address discrimination, increase resilience and reduce impact on LGBT+ • Draw on LGBT+ peoples own expertise • Adopt LGBT+ community led services • Training for heath care professionals and teaching for students • should not be optional or tokenistic but be embedded and integrated • Addressing homophobic biphobic and transphobic bullying in educational and workplace settings and wider society • Increase LGBT+ health evidence base - quality (datasets that are representative), research on trans and non binary populations, greater research on intersectionality in LGBT+ • Include SOGI in all health population studies including longitudinal data to allow causal pathways to be explored • 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 Joanna Semlyen July 5 2018, POST

  17. Thank you! J.Semlyen@uea.ac.uk @Dr_Jo_S www. Joanna Semlyen July 5 2018, POST

  18. REFERENCES 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. Ellis, S. J., Bailey, L., & McNeil, J. (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. Semlyen, J. (2015). Health psychology. In The Palgrave Handbook of the Psychology of Sexuality and Gender (pp. 300-315). Palgrave Macmillan, London. 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., & Kunasegaran, K. (2016). Understanding barriers to cervical screening uptake in trans men: an exploratory qualitative analysis. The Lancet, 388, S104. Hulbert‐Williams, N. J., Plumpton, C. O., Flowers, P., McHugh, R., Neal, R. D., Semlyen, J., & Storey, L. (2017). The cancer care experiences of gay, lesbian and bisexual patients: A secondary analysis of data from the UK Cancer Patient Experience Survey. European journal of cancer care, 26(4), e12670. Semlyen J. Recording Sexual Orientation in the UK: Pooling Data for Statistical Power. American Journal of Public Health. 2017; 107:1215-7. Semlyen, J., Ali, A., & Flowers, P. (2017). Intersectional identities and dilemmas in interactions with healthcare professionals: an interpretative phenomenological analysis of British Muslim gay men. Culture, health & sexuality, 1-13. 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

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