1. LGBT+ Health inequalities: Research evidence
Dr Joanna Semlyen
@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 , 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 %
Modelled estimate by Public Health England 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 , POST

4. Census 2021
Very real opportunity to establish size of LGBT+ population by inclusion of SOGI Qs
Joanna Semlyen July , 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
Why
How
In health
Exacerbated by and as coping strategy
Joanna Semlyen July , 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 , POST

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

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

13. UK DATA: SEXUAL ORIENTATION, Alcohol, smoking and BMI
Smoking and hazardous alcohol use (Hagger-Johnson G, Taibjee R, Semlyen J, et al )
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 , 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, , 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 , 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 , 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 , POST

17. Thank you! J.Semlyen@uea.ac.uk @Dr_Jo_S www.
Joanna Semlyen July , 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 ). 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:
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