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LGBTQ+ equality in critical condition?

22 November 2021

Before the pandemic, LGBTQ+ people were marginalised in healthcare. Anna Scott asks if the situation has deteriorated.

During the first lockdown last year, the charity LGBT Foundation surveyed LGBTQ+ people living in the UK to understand their experiences of living through the Covid-19 pandemic. Like many marginalised groups in society, LGBTQ+ people were more likely to be disproportionately affected by Covid-19. Alongside fears about safety and isolation in their homes, respondents cited issues accessing healthcare (LGBT Foundation, 2020).

Reduced access to healthcare for non-Covid-related issues has been an issue for everyone during the pandemic, and the LGBTQ+ community is no exception. Sixteen per cent of those surveyed said they had been unable to receive healthcare for non-Covid related issues, 34% had had a medical appointment cancelled and 23% had been unable to access medication – or had worried that they might not be able to (LGBT Foundation, 2020). All of these figures were higher for LGBTQ+ people from ethnic minorities, those with disabilities and trans and non-binary people (LGBT Foundation, 2020).

Unfortunately, disparities in healthcare for LGBTQ+ people are nothing new. In March 2019, the government’s then minister for women and equalities, Penny Mordaunt, appointed for the first time a national adviser for LGBTQ+ health in the NHS and an advisory panel tasked with, among other roles, improving access to and tackling inequalities in healthcare for LGBTQ+ people. ‘Wherever the question is asked, LGBT people experience poorer outcomes in healthcare,’ Dr Michael Brady said on his appointment to the role (LGBT Foundation, 2020).

An entrenched problem

The launch of the advisory panel followed the government’s 2017 National LGBT Survey of more than 108,000 people from the LGBTQ+ community living in the UK. This report found that of the 24% of respondents who had accessed mental health services in the preceding 12 months, 28% said it was ‘not at all easy’ to access healthcare (Government Equalities Office, 2018).

A report from the same year found that one in eight LGBTQ+ people (13%) had experienced some form of unequal treatment from healthcare staff because of their sexual orientation (Stonewall, 2018a). At the time, Ruth Hunt, then Stonewall’s chief executive, wrote: ‘While there are committed individuals and organisations doing outstanding work, this report shows that instances of discrimination, hostility and unfair treatment in healthcare services are still commonplace’ (Stonewall, 2018a).

One issue is lack of knowledge among healthcare professionals on how to provide the best care for LGBTQ+ communities. ‘Healthcare providers often just make an assumption of heterosexuality meaning that you have to disclose,’ one respondent told the government survey. ‘For example, if you say “my partner…” when discussing something, I always get the GP/mental health worker/counsellor/nurse saying “he” in their response, automatically assuming it is a man, when it is a woman. This has been ongoing for years. Training needs to be provided to healthcare professionals to not make assumptions’ (Government Equalities Office, 2017).

These issues have not gone away. A 2021 scoping review of UK evidence describing LGBTQ+ health inequalities in relation to cancer, mental health and palliative care indicated that ‘LGBT+ people were more likely to have a negative experience or outcome when being diagnosed, receiving treatment or in post-treatment, compared to the cis-heterosexual population.’ This was thought to be due to ‘the absence of LGBT+ specific care and attention from healthcare providers’ (McDermott et al, 2021).

Stonewall’s associate director of policy and research, Eloise Stonborough, says: ‘LGBTQ+ young people have always faced distinct challenges, from homophobic, biphobic and transphobic bullying to young trans people experiencing unacceptably long wait times to access vital healthcare. In the fallout of the coronavirus pandemic, many of these problems have become worse. Many LGBTQ+ young people have been cut off from spaces where they could be themselves and countless healthcare appointments have been delayed, particularly impacting trans youth.’

One respondent told the LGBT Foundation’s survey in April 2020: ‘Mainstream providers are usually ill-equipped and lack knowledge to be able to provide the best care for LGBT communities. If I’m accessing services at an LGBT charity, I would feel safer because they know they will get the challenges I’m facing, without having to educate mainstream professionals.’

Worsening still

It’s clear that lockdown has highlighted existing health inequalities for the LGBTQ+ community across a range of ages. A survey of secondary school pupils in April 2021 found that 55% of LGBTQ+ 11- to 18-year-olds were feeling lonely and separated from the people they are closest to, compared with 26% of their non-LGBTQ+ peers (Just Like Us, 2021).

Mental health has worsened for 68% of young LGBTQ+ people during the pandemic, compared with 49% of non-LGBTQ+ young people surveyed (Just Like Us, 2021). ‘Self-harming among gender-diverse people has increased by 7%, compared with 2% in cisgendered people,’ writes Callum Phillips in the BMJ. ‘In the same period, the 34% of LGBTQ+ people reporting “poor” or “extremely poor” mental health has almost doubled to 61%’ (Phillips, 2021).

For trans and non-binary people in particular, lockdown has meant access to specific healthcare has deteriorated. Before the pandemic, three in five trans people said they’d experienced a lack of understanding of their specific healthcare needs when accessing healthcare services (Stonewall, 2018b). During the crisis, services suspended face-to-face appointments, did not accept new referrals and redeployed staff (LGBT Foundation, 2020). Lockdown has also meant limited access to sexual health services, and mixed messaging about access to HIV medication and sexually transmitted infection testing and clinical services (LGBT Foundation, 2020).

Emma Tomlin, lead for Central London Community Healthcare (CLCH) Trust’s Sexual Health South West London service, says all groups have been affected by the pandemic, but for LGBTQ+ young people who may not have disclosed their sexuality, lacking a safe space to discuss their healthcare has been particularly detrimental, as has the one-off telephone triage in place at the onset of the pandemic.

 ‘Services continued for young people but were not advertised widely, so clients may not have known they existed,’ she says. ‘A concentration on telephone consultation – which can be advantageous for some clients – may not have been useful for this group, who may need to build up more of a relationship with staff to disclose any issues.’

Monitoring disparities

Many of the concerns regarding LGBTQ+ people’s access to healthcare at the start of the Covid-19 crisis appear to have been borne out, but as we emerge from the pandemic, it’s not yet clear what the reality is for access to healthcare for young LGBTQ+ people and families. One thing does appear clear – a lack of data. ‘There has been alarmingly little research into the impact of the Covid-19 pandemic on the UK LGBTQ+ population, despite known pre-existing health inequities’ (McGowan et al, 2021). Dr Michael Brady told the BMJ: ‘Wherever you meaningfully look for LGBTQ+ health inequalities, you find them. And yet we’re still not properly looking’ (Phillips, 2021).

However, the government is continuing to monitor, review and collect data on the disproportionate impact of Covid-19 on certain communities, a Department for Health and Social Care spokesperson says. ‘Every person has the right to access the healthcare they need and we are committed to ensuring the needs of the wider LGBT+ community are considered and reflected in our health system.’

The same applies in Northern Ireland. A spokesperson for the Health and Social Care Board says: ‘Given the ongoing efforts to deal with the pandemic and the increased demand for unscheduled care services, it has not been possible to fully assess the impact that Covid has had at a population level or on different sections of the community.

‘However, as the trusts plan to rebuild services, they will take into account the need to promote equality of opportunity across the nine equality categories as part of their ongoing commitment to their equality obligations.’

One of the roles of Public Health Scotland (PHS) is to provide evidence and data to support the improvement of services at national and local levels, such as measuring the use of health services by equity group. ‘PHS continues to monitor and assess a wide range of impacts on people and the healthcare system from the COVID-19 pandemic,’ a spokesperson says.

Welcoming posters in waiting rooms and ensuring that websites are inclusive and engaging will all make a difference

What’s your role?

At CLCH Trust, a limited open-access service for young people was provided as soon as restrictions allowed. ‘In some instances our health adviser team were able to conduct telephone conversations with young people with them whilst they were in clinic – but in a separate room following a clinical consultation,’ Emma says. ‘This helped build relationships for further remote/virtual consultations. We also worked with our partner agencies, who offered outreach services and ongoing counselling to young people through virtual sessions.’

 It appears too soon to say that access to healthcare services for LGBTQ+ people will improve. But in the meantime, community practitioners (CPs) are in a vital position to offer support and signposting for young LGBTQ+ people at school and LGBTQ+ families. 

 Measures such as welcoming posters in waiting rooms and ensuring that websites signposted to are inclusive and engaging will all make a difference. So too will targeted services to LGBTQ+ young people with well-trained staff who are aware of the needs of this group. ‘[They] need understanding and support, together with routine enquiry to include all types of sexuality and to avoid a heteronormative approach,’ Emma says.

‘Training is crucial for CPs,’ she continues. ‘At CLCH Trust, staff are enabled to develop the skills and knowledge to understand equality, diversity and inclusion within the context of the diverse communities it serves. Training has been extended in this area at the sexual health service to all staff, including reception and front-of-house staff, and it has a highly engaged user group with representatives from several LGBTQ+ groups within the boroughs we serve.

 

‘A well-trained, non-judgemental, welcoming, inclusive staff group – especially around the language used – is essential, as well as engaging with community LGBTQ+ support groups and patient user groups, which helps ensure services are fit for purpose.’

It’s not just up to CPs, however; teachers and school leaders can play a role too, and more funding seems a likely need. Eloise concludes: ‘It’s also vital that the NHS and the government address the under-resourcing of specialist healthcare services for trans people, including trans young people, and ensure that all young lesbian, gay, bi, trans and queer young people can get the support they need to thrive as themselves.’


Resources


References:

Barnardo’s. (2020) How coronavirus has affected the LGBTQ+ community. See: www.barnardos.org.uk/blog/how-coronavirus-has-affected-lgbt-community (accessed 25 October 2021).

Government Equalities Office. (2018) National LGBT survey: summary report. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/722314/GEO-LGBT-Survey-Report.pdf (accessed 25 October 2021).

Hunte, B. (2020) Lockdown: suicide fears soar in LGBT community. BBC News. See: www.bbc.co.uk/news/health-53223765 (accessed 25 October 2021).

Just Like Us. (2021) LGBT+ young people twice as likely to feel lonely and worry about mental health daily than peers. See: www.justlikeus.org/single-post/lgbt-young-people-mental-health-coronavirus (accessed 25 October 2021).

LGBT Foundation. (2020) Hidden figures: the impact of the Covid-19 pandemic on LGBT communities in the UK. See: https://s3-eu-west-1.amazonaws.com/lgbt-website-media/Files/7a01b983-b54b-4dd3-84b2-0f2ecd72be52/Hidden%2520Figures-%2520The%2520Impact%2520of%2520the%2520Covid-19%2520Pandemic%2520on%2520LGBT%2520Communities.pdf  (accessed 25 October 2021). 

LGBT+ Hero. (2020) The LGBTQ+ lockdown wellbeing report. See: www.lgbthero.org.uk/the-lgbtq-lockdown-wellbeing-report (accessed 25 October 2021).

McDermott E, Nelson R, Weeks H. (2021) The Politics of LGBT+ Health Inequality: Conclusions from a UK Scoping Review. International Journal of Environmental Research and Public Health 18(2): 826.

McGowan VJ, Lowther HJ, Meads C. (2021) Life under COVID-19 for LGBT+ people in the UK: systematic review of UK research on the impact of COVID-19 on sexual and gender minority populations. BMJ Open 11: e050092.

Phillips C. (2021) How Covid-19 has exacerbated LGBTQ+ health inequalities. BMJ 372: m4828.

Stonewall. (2018a) LGBT in Britain: health report. See: www.stonewall.org.uk/system/files/lgbt_in_britain_health.pdf (accessed 25 October 2021).

Stonewall. (2018b) LGBT in Britain: trans report. See: www.stonewall.org.uk/system/files/lgbt_in_britain_-_trans_report_final.pdf (accessed 25 October 2021).  

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