Lesbian, Gay, Bisexual and Transgender (LGBT)

Introduction

In law, the term “LGBT” covers two Equality Act 2010 Protected Characteristics: sexual orientation and transgender.  However, for the purposes of understanding different experiences and needs, the term LGBT is used here to cover four distinct groups with very different needs and expectations:

  • Lesbian - a woman who is attracted to other women
  • Gay - a man or woman who is attracted to people of the same gender
  • Bisexual – a person attracted to the same gender and/or opposite gender
  • Transgender – a person whose gender identity and/or gender expression differs from the sex they were assigned at birth. 

For clarity, transgender is not the same as transsexual man / transsexual woman which describes someone who has permanently changed (or seeks to change) their bodies through gender reassignment and who identifies as being simply a man or woman (or indeed a gay man or lesbian woman).  Transvestite describes anyone who wears clothes associated with a different sex and is not included in this evidence review. These terms are used interchangeably, and some may disagree with these definitions.  There are also a variety of different sub-cultures that exhibit different characteristics and health needs.

There are two additional groups – men who have sex with men (MSM) and women who have sex with women (WSW).  These people do not identify as gay or lesbian and would not consider themselves to be part of the LGBT community, but because of common behaviours may also share similar inequalities and health risk factors.

LGBT people should not be defined by their sexuality alone.  Within the LGBT population there will be people who are disabled or also from a Black or Minority Ethnic Background. The varying needs of these ‘minorities within minorities’ are discussed below.

Key inequalities and risk factors

There is a lack of high quality, large scale research around the needs of LGBT people. The available evidence 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.

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.

There is evidence that inequalities exist between LGBT people and the general population against the majority of the health and social care indicators in the Adult Social Care Outcomes Framework and the Public Health Outcomes Framework which also covers wider determinants of health.

Lesbian women

Research indicates that lesbian women do not seek intervention or support from the health sector and that they are less likely that heterosexual women to respond to preventative healthcare messages (The Department of Health, 2009). The table below outlines some of the key health inequalities for these women.

Topic

Inequality

Smoking

Young lesbian and bisexual women almost 10 times more likely to smoke at least weekly

25% of lesbian women are smokers compared with 15% of heterosexual women

Alcohol

Lesbian and bisexual women are at an increased risk of binge drinking and report higher alcohol consumption than heterosexual women

Lesbian and bisexual women are more likely to report alcohol-related social consequences and to have sought help for an alcohol problem

Weight problems

There is some evidence that lesbian women are more likely to have a higher BMI than heterosexual women

Drug use

20.7% of lesbian/bisexual women reported using any drug in the past year (compared to 6.9% of heterosexual women)

8.2% of lesbian/bisexual women reported using a stimulant drug in the past year (compared to 6.9% of heterosexual women)

6.6% of lesbian/bisexual women reported using a class A  drug in the past year (compared to 2.2% of heterosexual women)

Sexual health

A significant percentage of women who have sex with women (WSW) who attend GUM clinics receive a diagnosis. Almost all WSW engage in  sexual practices which could transmit STIs yet most lesbian and bisexual women (6/10 women) report it difficult to find relevant sexual health information

Mental health

LGBT people are at an increased risk of self-harm with lesbian women and gay men at more risk than bisexual men and women

Higher risk of mental illness than the general population

40% of lesbian women report negative or mixed reactions from mental health professionals when the disclosed their sexual orientation

1/5 lesbian women report a mental health professional making as causal link between their sexual orientation and mental health problem

Cancer screening

Lesbian women are less likely to attend routine screening for breast and cervical cancer so may be less likely to benefit from early detection of these diseases

Lesbian women are less likely to be told that they are at risk of cervical cancer and some women have reported being refused a smear test

Lesbian women have a slightly increased risk of breast cancer due to the fact that they are less likely to have children; more likely to be overweight; and more likely to drink alcohol

Healthcare satisfaction

Lesbian women are less likely to report satisfaction with healthcare and a third of lesbian women have not told their healthcare provider their sexual orientation

5/10 lesbian and bisexual women have had a negative experience of healthcare in the last year and 4/10 have experienced a healthcare provider assuming that they were heterosexual

Lesbian women can experience discrimination during pregnancy and childbirth. For, example the non-biological birth mother may be excluded form discussions or decisions

It is incorrectly perceived that as lesbian women do not have sex with men that they cannot contract STIs or are at a lower risk than heterosexual women.  Note that lesbian identity does not necessarily reflect a lifetime of same-sex relationships (one study shows 85% have previously had sex with men) and some STIs (including genital herpes and warts) have been diagnosed with women who have had no sexual history with men (The Department of Health, 2007i).

Gay men

Caution should be exercised not to define the needs of gay men by their sexuality or sexual activity: whilst HIV infection is a key health concern, gay men experience other health inequalities not explicitly linked to sexual activity.

Topic

Inequality

Smoking

33% of gay men are smokers compared with 21% of heterosexual men

Weight problems

Gay men are more likely to engage in binge eating and purging. Eating disorders are likely linked to aspirations to the ideal gay male body shape which is both slim and muscular. Some subcultures ("tribes) are more likely to have higher BMI.

Mental health

Young gay men are particularly vulnerable to suicide and suicide attempts. The concerns behind these suicides and suicide attempts are complex and include the presence of other factors such as anxiety disorder. Some subcultures ("tribes") are more likely to suffer self-esteem issues leading to poor general health and riskier sexual practices

Higher risk of mental illness than general population that has been linked to discrimination and intimidation

1/3 of gay men report negative or mixed reactions from mental health professionals when the disclosed their sexual orientation

1/5 gay men report a mental health professional making as causal link between their sexual orientation and mental health problem

Sexual health

 

80% of all HIV infections acquired within the UK are transmitted through sex between men and the diagnosis rates of HIV amongst men who have sex with men (MSM) are increasing. Some subcultures ("tribes") are more affected than others.

HIV affects the immune system leaving those with HIV at an increased risk of other infections

Despite their increased risk of infection, uptake of HIV testing amongst MSM is not high

GP consultations are an opportunity for health promotion that is missed as half of gay men report that their GP does not know their sexuality

There has recently been a particular rise in the rates of gonorrhoea among gay men in England

Cancer

Prostate cancer is potentially more common among gay men and anal cancer is more common amongst gay men (20 times more common) and is associated with genital warts, hepatitis b, human papilloma virus, herpes simplex virus and being a current smoker. It is also associated with HIV infection

Healthcare satisfaction

Surveys around gay men’s use of healthcare reveal dissatisfaction with primary care. They report that the literature in waiting rooms is often aimed a families and rarely addressed issues relevant to themselves

Gay men report “shopping around” to find a sexual health clinic that was empathetic to their needs and only attending a clinic regularly if it was “gay friendly”

Bisexual men and women

Health and wellbeing of bisexual men and women

Bisexual women

Bisexual men

25% currently smoke

27% currently smoke

77% had a drink in the last week and 37% drink three or more days a week

74% had a drink in the last week and 40% drink on three or more days per week

57% have been tested for STIs (compared to 44% of lesbian women who have been tested)

38% have never been tested for an STI (compared to 25% of gay men)

11% have never had a cervical screen (compared to 7% of women in general)

49% have never had a HIV test (compared to 29% of gay men)

7% attempted to take their own life in the last year

5% have attempted to take their own life in the past year (compared to 3% of gay men and just 0.4% of men in general)

29% have deliberately self-harmed in the last year (compared to 18% of lesbian and 0.4% of the general population)

11% have harmed themselves in the past year (compared to 6% of gay men and 3% of men in general)

3/10 have an eating disorder (compared to 2/10 lesbian women and 1/20 of the general population)

51% have had problems with their weight or eating in the past year (compared to 6% of gay men and 4% of men in general)

¼ experience domestic violence

51% have experienced at least one incident of domestic abuse since he age of 16 (compared to 17% of gay men)

¾ say that they are in good health

28% report being in fair or bad health (compared to 16% of men in general)

51% have had a negative experience of healthcare in the past year

1/3 who have accessed healthcare in the past year have had a negative experience relayed to their sexual orientation

66% are not out to their GP or other healthcare provider (compared to 46% of lesbian women)

60% are not out to their GP or other healthcare professions (compared to 30% of gay men)

 

50% have taken drugs in the last year (compared to 12% of men in general)

Evidence concludes bisexual men: are less aware about STIs with materials targeted at gay men (with which they do not identify); 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.

Trans people

Research is particularly limited (outside of the gender reassignment pathway of care) but available research suggests this group is particularly vulnerable to extremely poor mental and physical health outcomes and poor service provision.  Particular concerns among young trans people are poor housing, financial difficulties, access to healthcare, a lack of family support, higher rates of substance abuse, and high risk sexual behaviours.

The largest survey of trans people’s mental health in Europe was conducted in 2012:

Mental health problems

 

Feelings relating to being trans

Negative experiences

Lifestyle behaviours

Experience of service use

36% identified as having mental health issues

Almost 1/5 identified as having a learning disability or impairment

66% had used mental health services for reasons other than access to gender reassignment

31% were currently using anti-depressant medication

53% had self-harmed at least once

11% were currently self-harming

63% have thought about attempting suicide the last year

33% had attempted suicide more than once; 3% had attempted more than 10 times

23 years was the average age at which people started to live part time in their felt gender

31 years was the average age at which people started to live full time in their felt gender

13% did not want to undergo any form of transition

19% had experienced sexually harassment for being trans within the last year

6% had being raped for being trans within the last year

17% had experienced domestic violence for being trans within the last year

52% had experience problems with work due to being trans

19% had been homeless at some point

24% had used drugs in the last 12 months

19% were current smokers

62% responded to questions which suggested alcohol dependency

65% had experienced at least one negative experience of general physical health services

63% had experienced at least one negative experience of mental health services

There is a broad evidence base of LGBT people experiencing of poor access to services and treatment, compounded by fear of discrimination.

Young LGBT people

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

Topic

Inequality         

Mental health

4 times more likely to suffer major depression

3 times more likely to be assessed with generalised anxiety disorder

Males are seven times more likely to have attempted suicide and three times more likely to have suicidal intent

Healthy lifestyles

Lesbian and bisexual girls are 10 times more likely to smoke than their heterosexual peers

Illicit drugs may be an increased risk for some young gay and bisexual young men

Lesbian and bisexual girls are twice as likely to have consumed alcohol in the past month

Lesbian and bisexual girls are one and a half times more likely to have engaged in binge drinking in the last year

Lesbian and bisexual girls are nearly three times as likely to have consumed a first alcoholic drink before age 12

Young LGBT people are three times more likely to use MDMA/ecstasy

Young LGBT people are eight times more likely to use ketamine

Young LGBT people are 26 times more likely to use crystal methamphetamine

Violence and victimisation

78% of LGBT people under the age of 18 had experienced verbal abuse

23% of LGBT people under the age of 18 had been attacked by another pupil

Young LGBT people are more likely to suffer from bullying at school than their peers although rates have fall over the past 15 years with the number of schools explicitly saying that homophobic bullying is wrong doubling. However, the use of homophobic language remains endemic (Stonewall, 2015a).

Sexual behaviour and the risk of HIV

Young gay men are becoming sexually active from the age of 14 and may not be aware of the risks from unprotected sex

Learning from the National Children's Bureau 2016 report may also be relevant as it sets out how gender impacts on coping strategies and help-seeking behaviours, including children and young people who identify as trans or non-binary.

Prevention, Care and Support

An innovative programme called “Identity” is running at the Brakenhale in Bracknell.  The drop-in sessions started in 2015 as a tolerant, accepting and therefore safe environment for young people to share experiences of and develop resilience and response strategies around issues such as identity, self-esteem, disclosure and bullying. 

Significantly, the group is also outward facing and seeks to challenge misconceptions and promote understanding, tolerance and acceptance of wider equality issues by proactively engaging students and staff through assemblies, activities and fundraising. Hearing the voices of young people has led to a number of school policies being updated, with plans for additional support for staff to help them engage and support young people coming to terms with their identity.  The scheme is working towards the national Stonewall School's Champion Programme Bronze Award in 2016. 

For more information for your school or college, email the Identity programme direct at identity@brakenhale.co.uk.

Older LGBT people

Older LGBT people have similar needs to that of the wider older person population, however, service commissioning and provision overlooks needs specific to this group. In terms of independence, personalisation and risk of social isolation, LGBT older people are more likely to live alone and have fewer support networks than the general older person population.  Who will love me when I’m 64? (Relate, June 2013) makes clear the importance of couple, familial and social relationships on mental health and the impact of significant life events (e.g. death, divorce, caring responsibilities) on the mental health of older people which are compounded for older LGBT people. 

In determining care needs in later life, older LGBT people have extra concerns around entering residential accommodation due to isolation and discrimination and the need, therefore, the hide their sexual orientation.  Older LGBT people are often “hidden service users” as 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.

LGBT people with disabilities

Disabled people experience challenges expressing and developing their sexuality and sexual identityEvidence suggests 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.

LGBT group

Inequality

Comparison group

Older LGBT people with a disability

37% did not access the health services they felt they needed in the past year

28% disabled heterosexual people

23% did not access the mental health services they felt they needed in the past year

6% of disabled heterosexual people

19% did not access social care services they felt they needed in the last year

10% of disabled heterosexual people

Gay and bisexual men with a disability

29% currently smoke

26% of gay and bisexual men in general

55% had used recreational drugs in the past year

51% of gay and bisexual men in general

7% had attempted suicide in the past year

Higher than gay and bisexual men in general

15% had self harmed in the past year

Higher than gay and bisexual men in general

63% had experienced domestic violence at least once since the age of 16

Higher than gay and bisexual men in general

27% had never had a HIV test

30% of gay and bisexual men in general

Lesbian and bisexual women with a disability

10% had attempted suicide in the past year

Higher than gay and bisexual women in general

31% had self harmed in the past year

Higher than gay and bisexual women in general

39% had experienced domestic violence at least once since the age of 16

Higher than gay and bisexual women in general

35% were not out to their GP or other healthcare professional

49% of gay and bisexual women in general

61% had had negative experiences of healthcare in the past year

52% of gay and bisexual women in general

(Varney, 2013)

BME LGBT people

BME LGBT health needs have almost been completely overlooked in research conducted in the UK.

There is variation between BME LGBT people and heterosexual population and different ethnic groups of LGBT people in health risks and behaviours:

  • higher smoking rates than heterosexual BME individuals
  • higher risk of cardiovascular disease and cancer compared to both white lesbian and bisexual females and heterosexual BME women
  • gay African-Caribbean men in the UK are twice as likely to be living with HIV than White gay men
  • BME lesbian and bisexual women are more likely to be overweight compared to their heterosexual peers
  • BME communities are disproportionately affected by violence, abuse and harassment
  • African-Caribbean men in general are more likely to receive a diagnosis of schizophrenia and are three times more likely to be sectioned under the Mental Health Act

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 likely to experience physical abuse and harassment from strangers than White LGBT people.

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).

LGBT group

Inequality

Comparison group

Young BME LGBT people aged 11 to 19

76% BME gay and bisexual boys have thought about taking their own lives

56% of White gay and bisexual boys

83% BME lesbian and bisexual girls deliberately self harm

56% of White lesbian and bisexual girls

BME lesbian and bisexual women

33% currently smoke

28.7% of all lesbian and bisexual women

1/3 drink three or more days a week

25% of women in general

44%  have taken drugs in the last year

35% of all lesbian and bisexual women

55% have been screened for STIs

47% of all lesbian and bisexual women

19% have never had a cervical screen

16% of all lesbian and bisexual women

7% have attempted to take their own life in the past year

5% of all lesbian and bisexual women

26% have deliberately harmed themselves in the past year

20% of all lesbian and bisexual women

21% have an eating disorder

Approx. 21% of all lesbian and bisexual women

27% have experienced domestic violence

Approx. 27% of all lesbian and bisexual women

54% have had a negative experience of healthcare in the past year

52% of all lesbian and bisexual women

BME gay and bisexual men

27% currently smoke

26% of all gay and bisexual men

53% have taken drugs in the last year

52% of all gay and bisexual men

5% have attempted to take their own life in the past year

3% of all gay and bisexual men

8% have harmed themselves in the last year

6.5% of all gay and bisexual men

15% have had problems with their weight or eating in the last year

21% of all gay and bisexual men

55% have experienced at least on incident of domestic abuse

23% of all gay and bisexual men

22% have never been tested for an STI

22% of all gay and bisexual men

24% had never had a HIV test

29% of all gay and bisexual men

37% have had a negative experience of healthcare in the past year

35% of all gay and bisexual men

36% are not out to their GP or other healthcare professional

33% of all gay and bisexual men

(Varney, 2013)

Facts, figures and trends

LGB population

Available data comes from the Office for National Statistics (ONS) Integrated Household Survey, (IHS), 2014 – a national survey containing information from over 420,000 respondents making it the largest social survey conducted by ONS.  It estimates 5-7% of people are LGB.

Trans population

In terms of numbers for transgender people, an estimated 1% of the population identify as transgender and 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).

Population estimates for sexual identity for Bracknell Forest are:

Estimated LGB population based on 7% of total population is 6,541 and estimated trans population is 934.

Want to know more?

The key inequalities and risk factors listed above provide insights into issues that need further consideration.

Berkshire Sexual Health Needs Assessment (Berkshire Public Health Shared Service, 2013) – the background, national contexts, epidemiology of sexual health covering populations at risk, projections and the corresponding sexual health services relevant to various STI and reproductive issues in Berkshire.

Gender and children and young people’s emotional and mental health: manifestations and responses A rapid review of the evidence (National Children’s Bureau, 2016) – sets out how gender impacts on mental health coping strategies and help-seeking behaviours, including children and young people who identify as trans or non-binary.

Improving data on users and usage  - There are significant gaps in the evidence of need of LGBT people particularly at a local population level. There is a similar lack of routine monitoring of sexual orientation and gender identity (The National LGB&T Partnership, 2015). The legal imperative behind this is the Equality Act (2010).

Encouraging discussion and disclosure - Disclosing sexual orientation remains a sensitive issue and this should be considered when seeking to gather new information or undertaking new research. Research shows that patients want to talk to healthcare professionals about their sexual orientation.  Whilst people prefer the healthcare professional initiate these conversations clinicians feel uncomfortable discussing issues around sexual orientation (Rogers, 2014).  This needs to be overcome if accurate recording and picture of needs is to be made.

http://www.safesexberkshire.nhs.uk/

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