Health: Lesbian, Bisexual and Trans Women
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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.