It has been widely reported that LGBTQ+ people in the UK experience poorer health outcomes than the general population, both in terms of mental health, but with increasingly more evidence of physical health disparities (Semlyen et al. 2016; Elliott et al. 2015; Varney et al. 2018; Hudson-Sharp & Metcalf 2016; Zeeman et al. 2019). We recently completed an evidence review funded by the Health Foundation that sought to outline health inequalities related to sexual orientation and gender identity. While research on this topic isn’t necessarily representative of the LGBTQ+ community more generally, with less research being conducted on the health of lesbian and bisexual women, and significantly less research on health disparities for transgender and gender-non-conforming people in the UK, there is a growing body of evidence exploring these health inequalities.
Robust research on the impact of COVID-19 on LGBTQ+ people is yet to be published. However, a number of surveys from LGBTQ+ organisations in the UK describe poorer mental health among this cohort, increased rates of isolation among older LGBTQ+ people and more younger LGBTQ+ living in hostile home environments, and further delays in access to gender identity clinics. This suggests that the pandemic will have exacerbated these inequalities, as with other protected characteristic groups (LGBTHero, The LGBTQ+ Lockdown Wellbeing Report; LGBT Foundation, Hidden Figures: The impact of the COVID-19 pandemic on LGBT communities in the UK). As such, addressing the health inequalities of LGBTQ+ people is more timely than ever.
So why is it that many LGBTQ+ people experience poorer health outcomes? Research has shown that there are a number of social determinants that affect everyone’s health and wellbeing, including employment, education, socioeconomic status, neighbourhood and housing. This piece explores one determinant that plays a distinctive role in the health disparities of LGBTQ+ people in the UK: stigma and discrimination.
Conceptualising stigma and discrimination as a social determinant of health
Stigma and discrimination play a unique role as a stressor and a contributor to health inequalities. Firstly, stigma and discrimination can manifest in a myriad of ways, each with a specific and distinct impact on the mental and physical health of LGBTQ+ people. In the literature, forms of stigma described include isolation, rejection, homo/transphobia, violence, victimization, and hetero/cisnormativity. These forms of stigma and discrimination can operate at a structural level – i.e. related to macro-level conditions such as institutional policies, legislation or community norms – or an individual level – such as microaggressions, verbal assaults, or even violence against LGBTQ+ people.
LGBTQ+ people may experience stigma differentially across educational settings, the workplace, health care spaces, transport, and elsewhere in their daily lives. For example, the 2018 National LGBT Survey found that that discrimination, harassment and bullying continue to disproportionately affect LGBTQ+ people in the workplace, with consequences such as restricted job choice, reduced progression, reluctance to be out at work, as well as the related stress and potential impact on health outcomes. Similar phenomena have been reported in educational settings; for example, the Stonewall 2017 School report found that bullying had a significant impact on the learning and future plans of LGBTQ+ people. Linked to this, managing sexual and gender identities across multiple sites or life domains – such as ‘code-switching’ between one’s personal and professional life – is itself a negative stressor for LGBTQ+ people.
There are further layers to stigma and discrimination to consider – stigma can function externally as a stressor for LGBTQ+ people, as described above, but also internally, manifesting as internalised homophobia and transphobia. Intra-community stigma exists in many forms; for example, HIV-related stigma within the gay male community, racism within the wider LGBTQ+ community, or transphobia within the LGB+ community. Finally, an intersectional lens is appropriate when conceptualising stigma in LGBTQ+ health research: LGBTQ+ individuals have multiple categories of identity, and these intersections mean that they experience stigma and discrimination uniquely.
How does stigma function as a determinant of health?
As we can see, stigma and discrimination can be complex and manifest in a myriad of ways. But how do these examples of stigma experienced in society by LGBTQ+ people function as determinants of health, or lead to inequalities in health and wellbeing for this group, which is made up of a wide variety of individuals and experiences?
The most common theoretical model used to explain disparities in health outcomes for LGBTQ+ people in the UK is Meyer’s minority stress theory, which suggests that people from minority groups experience long-term stress as a result of factors associated with their identity and society’s response to it. This model centres on the idea that the consequences of prejudice, stigma and discrimination are behind the disparities in health. Instances of stigma and discrimination, as described above, function as stressors for LGBTQ+ people, and this long-term stress in turn impacts negatively on their mental and physical health.
Life course theory proposes that the health of LGBTQ+ people is influenced by an accumulation of factors throughout different stages of their life, and multiple inequalities across a lifespan can impact sequentially and lead to significantly worse health outcomes. As such, older LGBTQ+ people who grew up in a society that was less accepting of them, or people who faced higher levels of stigma and discrimination in all walks of life as a result, experience a negative impact on their health and wellbeing. Indeed, research shows that disparities in health outcomes are more pronounced among older LGBTQ+ people in the UK (Beach 2019; Semlyen et al. 2016).
What can be done to address these disparities in health for LGBTQ+ people?
The NHS appointed Dr Michael Brady as National Advisor for LGBT Health in April 2019. He has stated that his focus will be on improving the healthcare experiences of LGBTQ+ people accessing services through the NHS and other public services, but also on reducing the health inequalities that LGBTQ+ people in the UK face. Priorities for doing so, from the LGBTQ+ action plan, include improving monitoring across health and social care services to develop more inclusive gender identity monitoring, improving healthcare professionals’ awareness of LGBTQ+ issues, and developing the evidence base around these health inequalities. We feel that any attempts to develop this evidence base should take into account the important role that stigma and discrimination play as determinants of the health and wellbeing of LGBTQ+ people in the UK specifically, as well as a range of other determinants including education, housing, and employment.
Finally, as we enter Pride month and reflect on and celebrate the progress made towards equality for LGBTQ+ people, it is important to consider the persistent health inequalities that exist both in the UK and across the world – particularly for those members of the LGBTQ+ community who are disproportionately affected by these inequalities, including transgender and gender-non-conforming people, and individuals with multiple protected characteristics, such as BAME LGBTQ+ individuals or LGBTQ+ people with disabilities. As Dr. Michael Brady outlines in a Pride month blogpost for the NHS, Pride is a time to increase efforts in highlighting and addressing health inequalities experienced by LGBTQ+ people. Pride is also a time for us to focus on addressing the root causes of these health inequalities and redouble our efforts to eliminate altogether the stigma still experienced by LGBTQ+ people in society and create a healthier, more equitable society for all.