Health: Lesbian, Bisexual and Trans Women
(9 years, 11 months ago)
Lords ChamberRead Hansard Text Read Debate Ministerial Extracts
Baroness Barker
To ask Her Majesty’s Government what the National Health Service is doing to improve the health of lesbian, bisexual and trans women.
Baroness Barker (LD)
My Lords, in 1999, shortly after I became a Member of your Lordships’ House, I met Lord Campbell of Croy at an event. During our conversation he said, with a note of some pride in his voice, that he had been the Member speaking in your Lordships’ House when the ladies abseiled in from the Gallery to protest against Section 28. Much has changed since then. Section 28 is now history and, as someone who suffers from vertigo, I have to say that I am glad we no longer have to descend by ropes; we can walk in and take our place alongside everybody else in your Lordships’ House.
Today is historic. This is the first time that we have ever had a debate in this House about lesbians, bisexuals and trans women, and their health needs in particular. I am not turning my back on our gay brothers but I just ask them: today, please don’t rain on our parade.
I am delighted to say that the noble Baroness, Lady Gould, has agreed to take part today. She is my predecessor as the chair of the gender identity forum, and she will be talking about the needs of trans women. This debate has been planned and is being followed by many members of our community. I wish to thank in particular Jane Czyzselska from DIVA magazine, and the readers who contributed points; Jess Bradley from Action for Trans Health; Ruth Hunt, the admirable new director of Stonewall and the Lesbian and Gay Foundation in Manchester, which, under the leadership of Siân Lambert, produced a report, Beyond Babies and Breast Cancer, which sparked today’s debate.
The NHS constitution says that it,
“provides a comprehensive service available to all”,
irrespective of,
“gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status”.
However, the problem is that we have a growing body of evidence that says that it does not do that.
In 2008 we had Stonewall’s report, Prescription for Change: Lesbian and Bisexual Women’s Health Check. There was a bisexuality health briefing in 2012, a GP survey covering 2012-13 and the Beyond Babies and Breast Cancer report. It may be small-scale and most of it is very qualitative data, but there are consistent findings that lesbians, bisexual women and trans women experience discrimination in the NHS. The problem is that lesbians are often lumped in together with gay men. The needs of gay men are not insignificant; they are very important, but they are different. On the other hand, lesbians are included in the health needs of all women, yet our health needs are very different. Somewhere along the way, principally because of a lack of awareness and training in NHS staff, we end up getting a very poor service.
Almost half the women who were surveyed for those reports were not out to their GP, and when they did come out their statements were ignored. Only three in 10 lesbian and bisexual women said that healthcare workers did not make inappropriate comments when they came out. I have a wonderful quote:
“I was once asked by a male GP if I was in a sexual relationship. To which I replied yes. He asked if we were using condoms. I said no. Before I could say anything else, he went on a 10 minute rant about using condoms, being on the pill, STIs. When he stopped for air, I replied that I would ensure that my girlfriend would take care from now on. He spluttered and went bright red before promptly stabbing me with an injection that I really didn’t need!”.
Another story is as follows:
“After coming out to a nurse at a GP practice when I went for a smear, she did not know whether to test me for chlamydia and suggested that I see next time if I’m ‘still …’—presumably she meant still lesbian! I haven’t been back to the GP since”.
That is the important thing, and I can attest to similar experiences myself over the past 30 years. When there is such an inappropriate response from a health worker, it completely undermines your confidence.
Very few lesbian and bisexual women have been properly tested for STIs, and those who do turn up at genitourinary medicine clinics have a much higher incidence of STIs than heterosexual women. Quite often, health workers give them the wrong information and advice. One woman said:
“I was treated for cervical cancer after receiving a positive smear. I was originally told that I didn’t need a smear as I had never had sex with a man”.
There are other ways of contracting this viral infection. Sometimes lesbians get a bit fed up with having to be the teachers of the health workers who should be dealing with us.
A number of reports both in this country and abroad have been published about the fact that rates of smoking and alcohol consumption are statistically higher among lesbians and the gay community. It is tough when you have to deal with discrimination every day, and sometimes it is hard to be as healthy and fit as you should be. Some of us make an effort. I am pleased to report that I managed to give up smoking two years ago and I am still going strong. But there is only one alcohol clinic that is specifically targeted at gay women, and that is Antidote, run by London Friend. The problem is that generic services really do not target their messages at lesbians at all.
I turn to cancer screening. Because of lifestyle factors, we know that lesbians and bisexual women have a higher rate of diagnosis, but again there are no specific services and very few specific messages targeted at women from our community. On mental health, the reports we have suggest that although many women live perfectly healthy and happy lives, there is an increased incidence of mental ill health. Its prevalence is greater still among bisexual women. I have to say that there are no data on any of these conditions to show what happens to lesbian, bisexual and trans women from black and minority ethnic communities. There are simply no resources. Lesbians cope well, but there are no mental health services that are particularly designed to help us, and as a consequence we have to be pretty resilient on our own.
Some things can be done that could make a difference. The biggest difference would be made if clinicians and front-line staff in primary care recognised and understood that some of us are gay. They should not always ask questions that presume we are not. Bless them, sometimes they say things for the most benign of reasons, but it is still discrimination and they need a lot of training to help them get over what is essentially a flaw in their medical practice. Some partnerships have been formed between certain specialist organisations and lesbian and gay community groups which have worked very well. Manchester has the Pride in Practice project where the Lesbian and Gay Foundation has worked with nurses and doctors so that they are trained to ask questions in a way that does not make a presumption about the person to whom they are talking.
There are many more things that could be done. I am not asking for special services. That is not going to happen, given the financial situation at the moment. The NHS is a service for us all and therefore some of us, because of our background, have the right to expect that that universal service will meet our needs.
I have four specific points to put to the Minister. The first is to ask when Public Health England will put forward a strategy for promoting the health and well-being of lesbian and bisexual women. There is one for gay men; there is not for lesbians and bisexual women. Secondly, will NHS England develop a data standard on sexual-orientation monitoring? At the moment there is no monitoring of the way in which we interact with the NHS. Thirdly, the biggest problem is that GPs simply do not know how to talk to us. Can the Minister work with the Royal College of General Practitioners to develop some standards for questions to be asked of patients in a non-pejorative way? Lastly, in our work with GPs, could the health outcomes of lesbians and bisexual and transsexual women be part of the overall monitoring of GP practice?
We are citizens of this country. We are taxpayers. We support the National Health Service. It is only fair that we should expect it to recognise that we exist and should be able to access those services with dignity like everybody else.
Lord Cashman (Lab)
My Lords, I congratulate the noble Baroness, Lady Barker, on introducing this extremely important topic. She rightly referred to the three lesbians who abseiled into your Lordships’ House. Why did they do that? They did it on the absolute principle of equality. From that brave fight against Section 28, which all parties were to recognise was wrong and should be repealed, came a determination that we would treat all our citizens equally.
The good news is that I prepared a very long speech. The even better news is that my computer refused to print it. I have yet to discover whether it was bi-phobic, transphobic or homophobic, or merely that the operator was technologically incompetent. I think that it was the latter. As a gay man, I will try not to rain on the parade of the important issues that we are discussing. Therefore I will not give a prepared speech, but, as Edgar says at the end of Shakespeare’s King Lear, I will:
“Speak what we feel, not what we ought to say”.
In the excellent work that is placed before us by the House of Lords Library it is clear that there is an inequality in access to health services for lesbians, and bisexual and trans women. It is clear in the sexual minorities report, which I have here and which conclusively looks at more than 2.1 million respondents, that the healthcare access and treatment experienced by people within GP services was poor and inadequate.
I must declare an interest as the co-founder of Stonewall. I want to refer to the Stonewall Healthcare Equality Index 2013. But before I do, I say also that I await eagerly the contribution of the noble Baroness, Lady Gould of Potternewton, who has a long and distinguished record within your Lordships’ House and beyond on the issues that we are discussing.
The really interesting part of the Stonewall Healthcare Equality Index 2013 is that,
“32 healthcare organisations entered, including mental health trusts, acute trusts, ambulance trusts, social enterprise organisations, community services, clinical commissioning groups and independent sector providers. The organisations provide services to over 15 million patients and are from across all regions of England”.
When you first read the report, you think it is good news, but the reality is that:
“A third of respondents said they felt the healthcare organisation they used was gay-friendly”—
in other words, two-thirds found that it was not. The report continues:
“Half of respondents felt they were treated with dignity and respect all the time”—
but what of the other 50%? The report also says:
“Two in five respondents felt comfortable telling healthcare professionals their sexual orientation all of the time”.
That was in 2013. I await the 2014 report because, despite the Government’s good intentions—I recognise that there are good intentions; there are enough reports and action plans on the way forward—I fear that the gap is widening rather than narrowing.
It is equally worrying that older gay, bisexual and trans women, as well as gay men, are increasingly fearful about what will happen to them when they approach social care in their later years. We must consider this with the utmost seriousness because I believe that access to health and healthcare systems defines the kind of civilised country in which we would like to live, and if we cannot serve the minorities of our society, we have failed.
There is a very interesting document in the Library, Advancing Transgender Equality: A Plan for Action—another one. The responses to the Government’s surveys indicate that,
“transgender people face persistent challenges in accessing public services … More than half of respondents said they suffered discrimination in accessing public services because of their transgender status … More than half of respondents said health was their most significant area of concern … Two thirds of respondents said they had experienced threats to their privacy (e.g. having one’s gender identity revealed at work without consent)”.
There is enough evidence for us collectively, on all sides of the House, to move forward with determination.
I believe that I have outlined quite clearly that there is inequality in healthcare services. I make a special plea on behalf of the trans community. Trans women and men are so often forgotten in the language of non-discrimination. Their needs are overlooked and it is shocking, indeed shameful, that the World Health Organization still classifies trans as a pathological disorder. I hope that the UK Government will lead discussions within the WHO to end that swiftly.
I also had the great good fortune to attend a Home Office LGBT internal networking group. It was a wonderful morning of sharing of experiences—good and some doubtful—of what it was like to work in the Home Office, and the Home Office is like any other big employer. There was a trans woman who stood up and gave her experience. At the end of her presentation there were questions and someone asked her, “What is it like at work? How are you described?”, and she said—I am paraphrasing—“Well, at work it is like it is for most people who are different. It is difficult. How am I described? I am described as ‘that thing’”. Can your Lordships imagine what that does to you and your mental well-being, let alone your physical well-being?
Now is the time to move forward. I look forward to hearing from the Minister about what action plans have been undertaken and what is actually being done within the NHS in England.
I have enjoyed speaking in this debate, although “enjoyed” is perhaps not the right word when we are talking about inadequate services and the expression of difference and human rights. I believe that access to decent healthcare is a human right. This country has a good and proud record on this, stretching back generations. However, I honestly believe that we need one more push so that we narrow the gap in accessing goods and healthcare services for good, decent, honourable women and men of this country, who deserve such. I thank your Lordships.
Baroness Gould of Potternewton (Lab)
My Lords, I, too, thank the noble Baroness, Lady Barker, for introducing this important debate. It may have been a very short debate and there may not be many of us who have participated, but the words that we have said will be on the record, which is the most important thing. I thank also my noble friend Lord Cashman for his kind remarks and for his being able to participate with his great experience on the subject.
As we have heard, there is no question but that people in the LGBT communities are more likely to report ill health and experience unfavourable and negative responses from parts of the NHS. Like the noble Baroness, Lady Barker, I will concentrate my remarks on trans women, for they and trans people in general often require the services of medical staff in a way that lesbian and bisexual women do not. Many trans women who consider and embark on transition require medical assistance such as psychotherapy, cross-gender hormone treatment and surgery.
It might be useful to give a brief explanation of the process of medically assisted transition and of where treatment is available. Initially, the individual’s GP refers the patient to a gender identity clinic, sometimes via a local mental health service. After a minimum of a year attending the gender identity clinic, the individual may be referred for various surgical procedures. Cross-gender hormone treatment does not usually start until after the second appointment at the clinic.
There are seven specialist clinics in England dealing with adults and three providers of gender assignment surgery, which take referrals from all over the country. The question has to be whether this is enough provision to satisfy the need, for the number of people seeking such medical assistance has increased by at least 11% each year since 2004, thereby substantially increasing the demand for the few specialist services which provide care and treatment for patients with gender dysphoria.
Some 7,700 people are being treated or waiting to be treated at gender identity clinics. Such clinics are exempt from the 18-week deadline to provide treatment on the grounds that they are currently classified as mental health providers, despite a government statement in 2002 that gender dysphoria is a widely accepted medical condition and not a mental illness. However, I understand that this is now under review. Can the Minister confirm that that is the case?
There are two areas where waits can occur: the initial referral to the clinic and any subsequent referrals for surgery. The average waiting time on both lists is currently around a year, but that time is likely to increase. Extreme examples of waits are not unknown, such as that of the woman who waited eight years for her first appointment at a gender identity clinic. Long waiting times can inevitably lead to anxiety, depression and even suicide attempts, and there is little support during that time for those patients. Surveys repeatedly indicate that between 30% and 40% of trans women have attempted suicide before or during treatment, a rate which drops close to the national average after treatment, which in itself says an awful lot.
This specialist service is now the responsibility of NHS England, which inherited a mixed system from various historical commissioning processes. The new centralised commissioning body should provide a more consistent approach for the benefit of trans women, who are becoming more aware about what treatment to expect and about their human rights.
To date, NHS England has produced an interim gender dysphoria protocol to be completed next year, as well as service guidelines. A task and finish group has been created to look at key areas. The latter arose after concerns raised by Healthwatch England and local Healthwatch committees around the country about trans people’s healthcare and treatment. Specifically, Healthwatch England identified miscommunication locally about who commissions or funds the service, considerable delays in accessing services, individuals being put on waiting lists when “money has run out” and changes in timelines for treatment. There is terrible inefficiency that means that individuals fall out of the access pathway and struggle to reaccess the service. One can only imagine the despair of the trans woman faced with such a dreadful situation.
It is disconcerting that issues that have been raised over the past decade were still being discussed at a consultation only last week. The consultation heard of a lack of patient care and the reluctance of GPs to refer to clinics or take responsibility for prescribing cross-gender hormones. Wider concerns were also expressed about health professionals’ treatment of trans people. Although there are trans women who receive satisfactory treatment, many others do not. That can arise because of our GPs’ lack of knowledge. As the noble Baroness, Lady Barker, said, GPs play an enormous role in ensuring that proper treatment is provided right across the field. GPs need to be provided with more detailed information so that they can ensure gender identity services in the process to transition. Lack of understanding by GPs and their staff can cause great distress. It is difficult enough to confide feelings of gender dysphoria to a doctor without feeling fear, guilt, shame and ridicule. All too often, trans people leave a consultation feeling worthless.
As for lesbian and bisexual women, examples of humiliation abound. For example, one woman says:
“I asked for advice on a gender identity issue and the doctor told me to go away once he’d stopped laughing”.
That can continue for life, as clearly shown by the trans woman who had been a female for 15 years who went to her GP for a flu jab and was called “Mr” very loudly in reception. When she expressed concern about the lack of confidentiality, she was told that revealing her birth gender was relevant to the procedure. The mind boggles. What utter and absolute nonsense that was, as it was in the case of a woman who went to a hearing consultant. He decided that it was appropriate to question her about her trans notes on her medical file.
That is just the tip of the iceberg. There are many more examples of stigma, discrimination and ignorance. Any kind of abuse of a patient is unacceptable. It is crucial that NHS England and all the services within the NHS safeguard patients from abuse of any sort.
To find the level of discrimination, evidence was collected last year which identified a number of allegations, 98 of which were reported to the GMC. Of those, 39% related to GPs, 22% to gender specialist services and 17% to mental health services. The GMC expressed interest in pursuing 39 of those cases, but it is not clear that any action has yet been taken.
Paragraph 59 of the GMC’s Good Medical Practice guidelines states:
“You must not unfairly discriminate against patients or colleagues by allowing your personal views to affect your professional relationships or the treatment you provide or arrange”.
It is the breaches of that rule that have caused many patients to have a complete lack of trust in their clinics. Additionally, more than half the complaints related to both gender specialist services and general practice with allegations of refusal to treat or refer—also directly prohibited by the GMC’s Good Medical Practice guidance. It may be because of the complete lack of solid research that some GPs have such bad attitudes. Most are unaware of what basic monitoring they should be carrying out for trans women or how to translate those results. Also, linked to this lack of research, oestrogen and hormone-blocking treatment is not currently licensed or regulated and therefore not always prescribed, but hormone therapy is essential to maintain the health of the trans woman. Further, it means that trans people can be tied to a GP who will prescribe, and face uncertainty if they have to move their home.
There are, however, discriminatory practices within the NHS itself. There is currently no national policy on access to gender-specific screening, such as prostate screening for trans women. The NHS pledges to all patients undergoing treatment which might affect their fertility that they will have access to reproductive services such as gamete storage so that in future they can, potentially, have children via IVF but there is substantial evidence of storage clinics turning trans women away. I wait to hear from the Minister what advice he will be giving to NHS England to correct these examples of discrimination, which I am sure he agrees cannot continue.
The only way to solve these injustices is for treatment and care to be clearly patient-centred and non-proscriptive, while recognising individual preferences and circumstances. I welcome the changes in the NHS protocols which recognise this solution, but I ask the Minister to try and get some sort of speed in the timescale for full implementation.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I begin by thanking my noble friend very warmly for securing a debate—the first one, in my experience—on the important issue of the health of lesbians, bisexual and trans women. These are women who may face discrimination by the NHS because of prejudice or, as we have heard, a lack of understanding about the particular health needs that they may have.
The noble Lord, Lord Cashman, spoke eloquently about the duties and principles of a civilised society in relation to minority groups of people such as these. The NHS constitution is our way of enshrining those principles in relation to the National Health Service. It commits the NHS to providing a comprehensive service available to all, irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity, or marital or civil partnership status. The service is designed to diagnose, treat and improve both physical and mental health. It has a duty to each and every individual whom it serves and it must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population.
However, despite this we recognise that discrimination still takes place. In my comments, I will highlight some of the work that we are taking forward to combat such discrimination. The Department of Health is funding a number of organisations to help tackle some of the challenges that lesbians, bisexual and trans women face when seeking to access health services. First, the department has awarded Stonewall £235,000 over three years for its Health Champions programme. This supports 20 NHS organisations a year to improve their knowledge and awareness of the health needs of lesbian, gay and bisexual people—if noble Lords do not mind, I will use the acronym LGB—and helps them to deliver a more personalised health and care service.
Secondly, the department is funding the Lesbian & Gay Foundation to carry out two projects over three-year periods. The first, with a grant of up to £140,000, focuses on the recruitment, training and empowerment of LGB community leaders, enabling them to engage with NHS structures. The second project, with a further £108,000, is its Pride in Practice project, which aims to increase LGB people’s access to appropriate healthcare.
Thirdly, the department is funding the National LGB&T Partnership with a grant of £186,000 this year. The partnership is made up of a number of organisations, and this funding enables them to work with Public Health England to ensure that LGBT people’s needs are included in their business plan priorities; with the Department of Health to produce an LGBT companion to the adult social care outcomes framework; and with NHS England on the future of gender identity services for adults.
The noble Lord, Lord Cashman, and the noble Baroness, Lady Gould, expressed concern about the classification of trans people. It is universally accepted that gender nonconformity is not a mental disorder. However, specialist services in this country are commissioned from mental health trusts, and input from psychologists and psychiatrists, among others, is essential to offer advice and assessment for people affected by concerns regarding their gender identity. Some patients will not require or wish to receive any hormonal, physical or surgical treatment, but improvement in the patient’s self-perceived psychological and emotional well-being is a key goal of treatment for all patients. I will be happy to write to noble Lords expanding on that.
I turn to my noble friend’s concerns, in particular about lesbian and bisexual women. She spoke of insensitivity by general practitioners towards lesbian and bisexual people. I am sorry to say that the experiences she recounted resonate with some of the briefing that I have received. In September this year, a study funded by the Department of Health saw experts examine data from over 2 million responses to the general practice survey of 2009-10, including 27,000 responses from people who identified themselves as gay, lesbian or bisexual. It found that lesbian, gay or bisexual people were up to 50% more likely than heterosexuals to report negative experiences with the GP services that they received. Admittedly, the figure was 1.7% of lesbian, gay and bisexual people who reported their overall experience with their GP as very poor, compared with 1.1% of heterosexual people: nevertheless, that is a statistically significant difference. All patients deserve high-quality care from their GP regardless of their sexual orientation. Patients expect their GP to offer the best care, so if ever there were an example of how important it is for GPs to use the results of the GP Patient Survey to improve the services that they offer, surely this is it.
With regard to training and asking the appropriate questions, which is clearly part of all this, we have asked Health Education England to ensure that the recruitment, education, training and development of the healthcare workforce generally results in patients, carers and the public reporting a positive experience of healthcare, consistent with the values and behaviours identified in the NHS constitution. The quality of care is as important as the quality of treatment. We also asked Health Education England to ensure that there is an increased focus on delivering safe, dignified and compassionate care in the education and training of healthcare professionals.
In response to my noble friend’s point about mental health, Public Health England recognises the increased risk of suicide and self-harm among lesbian, bisexual and trans women. As part of its response, it is developing a professional toolkit for nurses with the Royal College of Nursing on youth suicide prevention among lesbian, gay, bisexual and trans youth in order to ensure that young people get better support.
My noble friend asked about the possibility of a strategy and what we were doing to monitor data. Public Health England recognises the health inequalities affecting all three groups of women. Many of these issues were clearly set out in the lesbian, gay and bisexual and trans companion document to the public health outcomes framework, published last year by the National LGB&T Partnership. I do not have time to read out some of the key points from that, but it is worth studying because it presents a very good way forward.
Improving the quality of the data is an important aspect of this. Public Health England recognises the challenges involved in understanding at a population level the health of these women because of the lack of routine data collection. It and NHS England are working together with the National LGB&T Partnership to integrate sexual orientation monitoring alongside other demographic data collection across the NHS.
The noble Baroness, Lady Gould, spoke very powerfully, as she always does, about the position of trans people and, in particular, about waiting times. NHS England acknowledges that there are some system delays at both gender identity clinic level and surgery level. It has set up, as she mentioned, a task and finish group to look at the issue of delays and has engaged with the three surgical providers to discuss options. It is under no illusions about this. I am well aware that Healthwatch England has made its opinions very clear to NHS England, and I pay tribute to it for that.
In general in this area, NHS England has created a gender identity clinical reference group which has developed a new service specification and clinical commissioning policy. It has also established a transgender network designed to hear the views of people and to influence the strategic direction of services. It is organised and facilitated by the NHS England patient and public voice team.
The noble Baroness also mentioned the workforce. NHS England has confirmed that the number of surgeons contracted to provide feminising gender reassignment surgery is currently 1.5 whole-time equivalent. It hopes there will be an additional 0.8 whole-time equivalent available by the autumn of next year. Two surgeons are currently training to perform gender reassignment surgery and are employed by the NHS. There is another one whole-time equivalent capacity available, but this is not currently contracted by NHS England. Clearly, surgery of this kind is highly specialised. It takes at least six months’ additional training to learn these particular techniques, and trainees would normally be established consultants in neurology, gynaecology or plastic surgery.
As regards hormonal treatment, oestrogens are not authorised, licensed or regulated for the use of trans women. Consequently, GPs may refuse to prescribe them. Specialist clinics make recommendations for the prescribing and monitoring of these therapies but do not directly prescribe them or provide physical or laboratory monitoring procedures for patients. It is true that there are no preparations of oestrogen licensed for the treatment of gender dysphoria. NHS England’s specialised services circular 1417 sets out arrangements for prescribing and monitoring medications.
GPs undoubtedly have an important role in the healthcare of people with atypical gender identity development, not only around the time of their transition to a social role and physical development congruent to their gender identity but for the rest of their lives when they no longer have a need for specialised gender identity services. If I can expand on those remarks, I would be happy to write to noble Lords.
The noble Lord, Lord Cashman, asked what actions had been delivered from the actions plans. The Department of Health has delivered on all its commitments in the trans and LGB action plans. The Government Equalities Office will shortly publish a report on all the work carried out by government in this area.
Responsibility for improving the health of the nation lies with Public Health England and NHS England and I am pleased to say that both organisations are working to improve the health of these groups of women. My noble friend mentioned cervical screening. Public Health England’s NHS cervical screening and breast screening programmes are offered to all women irrespective of their sexual orientation although Public Health England is working with the Lesbian & Gay Foundation to support screening for lesbian and bisexual women. This is especially necessary in respect of the cervical screening programme, which encourages lesbians to be screened despite the common misconception that this is not necessary.
Public Health England also recognises that there are health inequalities which are common across all three groups of women, such as the significantly increased risk of mental ill health, self-harm and suicide and also issues specific to gender identity, such as the ease of access to gender identity clinics. Many of these issues have been clearly set out in the companion to the public health outcomes framework published by the National LGB&T Partnership. The partnership is also developing healthy living guides for trans people which cover a wide range of topics including sexual health, mental health and well-being, physical activity and diet. Public Health England acknowledges the challenges involved in understanding, at a population level, the health needs of these women because of the lack of routine data collection, about which I have already spoken. Therefore they are working together with stakeholders to integrate sexual orientation monitoring alongside other demographic data collected across the NHS.
As part of its response to the increased risk of suicide and self-harm among these groups, Public Health England is developing a professional toolkit for nurses with the Royal College of Nursing on youth suicide prevention among LGBT youth to ensure they get better support. That builds on previous work by the department to support young people’s mental health. In addition, Public Health England has been working in partnership with the Royal College of General Practitioners to raise awareness of sexual orientation through a new e-learning resource.
I turn briefly to the work that NHS England has been taking forward in respect of gender reassignment. Since April 2013, NHS England commissioned gender identity services, as the noble Baroness mentioned, and soon after this it established a gender identity clinical reference group, which comprises clinical staff, patients, carers and representatives of professional bodies. In June last year the group embarked on the development of a new service specification and clinical commissioning policy. A transgender network has been established to support that work, and now has more than 100 members. The network is designed to hear the views of stakeholders and to influence the strategic direction of services, and is facilitated by the NHS England patient and public voice team. In recognition of the time required to develop the new service specification, an interim gender protocol was adopted in July 2013, based on the NHS Scotland gender reassignment protocol.
Finally, I know there are concerns in the trans community about waiting times for treatment—I have covered those in my earlier remarks. However, I emphasise that once within a gender identity clinic, patients should receive appointments with the team at an interval appropriate to their need. NHS England is aware of the situation and has set up a task and finish group specifically to address issues around delays. As I have indicated, any delays before gender reassignment surgery are related to capacity problems among surgery providers. I understand that around 455 patients are waiting for surgery, at various stages of clinical readiness. The positive thing is that in future, NHS England will be in a better position to monitor that, as it will hold the data centrally.
In summary, although the legal framework is in place to make discrimination on the grounds of gender, sexual orientation and gender reassignment unlawful, and despite the fact that equality is enshrined in the NHS constitution, we acknowledge that discrimination sometimes still takes place. What we need to do now, building on the legal framework, is to strive to change hearts and minds to eradicate prejudice. However, of course, that is not just a role for government; surely we all have a role to play in that endeavour. Each one of us needs to be honest about our own prejudices, and work to establish a more equal and fairer society for all.