Lesbian, Bisexual and Trans Women’s Health Inequalities

Justin Madders Excerpts

Tuesday 10th March 2020 Commons Chamber

[Justin Madders (Ellesmere Port and Neston) (Lab)]

I am pleased to be responding to this debate, which falls near the beginning of LBT Women’s Health Week. The theme of this year’s week is visibility, so this debate itself provides an important opportunity to raise awareness of the health inequalities that affect women in LGBTQ+ communities. I know that the other place debated these issues as recently as last week, but as the hon. Member for Reigate (Crispin Blunt) said, this is the first time that these issues have been specifically discussed in this Chamber. The week provides an opportunity for communities, practitioners, local government, health and social care providers and commissioners of services, as well as ourselves in this place, to take a close look at what progress has been made in improving the health and wellbeing of all women in our communities and supporting them to take action, because, as we have heard in the debate today, there are some excellent examples of good practice and progress around the country but more needs to be done to support LBTQ+ women.

The hon. Member for Livingston (Hannah Bardell) opened the debate and said she hoped it would be conducted with respect and integrity, and I believe it has been. As always, she conducted herself with respect and integrity, and she spoke with great openness and sincerity about her own experiences, which I hope will prove an inspiration to others. I was particularly impressed by the humility she showed in recognising that her own position and privilege might have made it easier for her to come out than it would be for other people to do so, but I am sure it was still not an easy thing to do.

The hon. Lady spoke about the mental health challenges facing people and also issues in accessing healthcare. She gave us the staggering fact from a survey in Scotland that about half of all trans people have considered taking their own life. That was particularly worrying and concerning, and should cause us all to think about what more we can do. The personal testimonies she gave were extremely powerful and put many of the figures that we have heard today into a much more personal and meaningful context.

The hon. Member for Reigate was absolutely right to say that equality in law is not the same as equality in outcome, and he highlighted some of the findings from the Women and Equalities Committee report, which I will return to shortly. He was also right to highlight some of the initiatives that have been successful and also some of the areas where we need to do more.

It was a pleasure to hear from my hon. Friend the Member for Sheffield, Hallam (Olivia Blake); it was the first time I have heard her speak in the Chamber. She shone a spotlight on an area we do not talk about very much: the social care sector and some of the bullying and discrimination that is happening there. It is certainly the case that, as she said, much more education and training is needed. My hon. Friend was also right to say that the approach to health and care needs to be much more holistic to take account of the needs of the individual; she got the tone absolutely right in making that point.

The hon. Member for Runnymede and Weybridge (Dr Spencer) gave a very thoughtful speech, and one point I took from what he said was that we need a lot more data and research in these areas to really understand the issues that we are dealing with. The hon. Member for North Down (Stephen Farry) spoke very powerfully and movingly about the progress that has been made in Northern Ireland, but also about some of the challenges that are still faced there.

As we have heard during the debate, there are higher rates of poor mental health, misinformation about sexual health, difficulties in accessing healthcare, and experiences of discrimination, harassment and domestic abuse. There are multiple barriers facing LBTQ+ women that prevent them from having a healthy and happy life, and that is simply because of who they are.

Several Members mentioned Stonewall’s 2018 report, “LGBT in Britain”, and we must use that as a touchstone for what to do in future. It found a worryingly high rate of mental health issues suffered by LBT women. The report itself told of harrowing experiences of discrimination and harassment in daily life, rejection by family and friends and people being subjected to hate crimes just because of who they were. These things clearly all have a devastating impact on a person’s mental health.

Over a quarter of lesbians and 42% of bisexual women report having a long-term mental health condition, with bisexual women being four times more likely to have long-term mental health problems than straight women, and 28% of bisexual women and 40% of lesbians said they deliberately harmed themselves in the last year, compared with 6% of adults in general. The fact that incidents of self-harm are over four times greater for bisexual women and twice the rate for lesbians than for the general population should give us all cause to think about the difficulties these communities are facing. Some 19.2% of lesbian women and 30.5% of bisexual women also reported having an eating disorder. Despite the clear levels of need we have talked about, the 2018 national LGBT survey found that when it comes to accessing mental health care, about 50% of LGBQ women and 53% of trans women found accessing those services “not easy” or “not easy at all”. The LGB&T Partnership also found that lesbians, at 25%, and bi women, at 32%, are more likely to describe themselves as having fair or poor health than heterosexual women, at 21%. Studies have shown that lesbian and bisexual women also have higher risks of obesity and cardiovascular disease. Two national patient surveys in England found that the prevalence of all cancers is higher in lesbians, at 4.4%, and bisexual women, at 4.2%, than heterosexual women, at 3.6%. In terms of sexual health, less than half of lesbian and bisexual women have ever been screened for sexually transmitted infections, but half of those who have were found to have had an STI.

Despite the clear advice from Public Health England that all women aged 25 to 49 should be screened for cervical cancer, there are conflicting messages still from health professionals which mean that lesbian and bi women are much less likely to attend their cervical screening appointments, with one in five lesbian and bisexual women reporting having been told by a healthcare professional that they were not at risk of cervical cancer. Overall, lesbian and bisexual women are up to 10 times less likely to have had a cervical screening test in the past three years than heterosexual women, yet bisexual women are more than twice as likely to have cervical cancer than heterosexual women.

The picture for breast cancer screening is a little more positive, with four in five lesbians over the age of 50 having attended their breast screening invitation, which is a similar figure to that for heterosexual women. But trans women taking oestrogen may be at increased risk of breast cancer and may not be routinely invited for screening, particularly if the gender marker on their records is “male”. Macmillan also found that many breast health awareness messages are delivered to women when they attend clinics for contraception or cervical screening, meaning lesbian and bisexual women and trans men with breast tissue may be less aware.

There are serious concerns that poor access and poor experiences contribute to poorer health outcomes. The National LGB&T Partnership tells us that 8.1% of lesbians, 5.9% of bisexual and 15.4% of trans women experienced inappropriate questions because of their sexuality when accessing healthcare. In its report, Stonewall found that discrimination, both experienced and expected, can deter LGBT women from accessing healthcare when they need it, with one respondent saying:

“Medical professionals are not that good with lesbians. I don’t go to the GP very often because they’re not familiar with lesbian issues usually.”

That is disappointing to hear, because I often stand at this Dispatch Box and praise our wonderful NHS staff. We all know that they do a tremendous job under increasing pressure, but, as this report shows, while most health and social care staff do their best to deliver the best possible care, the fact that one in seven LGBT people avoids seeking healthcare for fear of discrimination shows that there are training issues. I will address those issues a little later.

A Women and Equalities Committee report in 2016 found that trans women face lengthy delays to accessing gender identity services, averaging a two to three-year wait. That is a very long time considering the constitutional target for referral to treatment is 18 weeks. That ought to be addressed as a matter of urgency. The 2018 national LGBT survey found that a quarter of trans women felt their specific needs in relation to their gender identity were ignored or not taken into account when accessing healthcare. Three in five trans people said they have experienced a lack of understanding of specific trans health needs by healthcare staff

The evidence is clear that there is a need for action to reduce health inequalities. Providing the best possible, high quality healthcare does mean delivering care without prejudice. It also requires an understanding of specific health needs and an understanding of the challenges particular communities face. Following the 2017 national LGBT survey, the Government’s Equalities Office produced an LGBT action plan in 2018 which, included more than 75 commitments across a whole range of areas. With regards to health there were commitments to

“ensure that LGBT people’s needs are at the heart of the National Health Service”,

including appointing a national adviser to provide leadership on reducing the health inequalities that LGBT people face, enhancement of fertility services for LGBT people, improving mental healthcare and improving the way gender identity services work for adults.

In the annual progress report for 2018-19, which was presented to Parliament, I know that some progress on those recommendations was made. The National LGBT health adviser was appointed and a funded programme to trial new approaches to tackling LGBT health inequalities was launched.

The Government said that it was their intention to deliver the remainder of the commitments from the action plan over the next three years. Will the Minister update us on how those plans are going along? In particular, the Government’s stated priorities for action are: looking at ways to improve the mental healthcare for LGBT people, developing a plan to reduce suicides among the LGBT population, and the transformation of adult gender identity services. There was also a pledge that NHS England would fund the Royal College of Physicians to develop the United Kingdom’s first accredited training course in gender medicine, which will begin accepting recruits shortly. I am not sure whether the progress report for 2019-20 has been published yet, but perhaps the Minister can update us on that and on what progress is being made and when the next report is due.

As we heard, in October last year, the Women and Equalities Committee published a report on health and social care in LGBT communities following its inquiry, which called for evidence on how well policy makers and service providers were taking into account the health and social care needs of LGBT communities. It received over 100 written submissions and heard oral evidence from people about their experiences, as well as community groups, advocacy organisations, policy experts, local authorities, public service providers and politicians.

As we heard, the report found that unsurprisingly, there are many significant health inequalities for LGBT communities and that they face numerous barriers in accessing health and social care. We are yet to see the Government’s response to the Committee’s report. While I appreciate that it was published just prior to Dissolution, it would be useful if the Minister indicated when the Government’s response to that will be provided.

There are many recommendations in the report—23 in total—and I will not talk about them all today, but I would like to draw one or two to the House’s attention. I agree with the report, Stonewall and the National LGB&T Partnership that monitoring both sexual orientation and gender identity is far too important to be left as an aspiration rather than a concrete goal. If monitoring remains optional, health disparities will continue and remain hidden across services if they choose not to implement it. I believe that all providers must implement sexual orientation and trans status monitoring alongside training for frontline staff to collect the data, so that as with all personal data, information on sexual orientation and trans status is collected and recorded sensitively.

The Committee also recommended that sexual orientation monitoring should be made mandatory across all NHS and state social care providers by October this year and that service providers that fail to implement it should face fines equivalent to those for not monitoring ethnicity. It also recommended that gender identity monitoring work should be accelerated with a view to creating a standard by the end of 2019 and then rolled out on a mandatory basis to the whole NHS and state social care providers by the end of the year. We know that one of the roles of the national adviser is to advise the Government on the implementation of sexual orientation monitoring across the NHS. Will the Minister update us on what progress has been made in implementing the plans and whether the recommendations will be completed in the timeframe set out?

The Committee’s report recommends that all NHS and social care providers should ensure that all staff understand their legal responsibility to deliver services that are inclusive of LGBT people. We have touched on the fact that training will play an important role, and I agree with the Committee that those responsible for the education and training of health and social care professionals should treat training on LGBT needs as being as integral as any other training.

I support Stonewall’s call for all health and social care staff to receive LGBT-inclusive training on meeting the needs of LGBT people throughout their careers. Again, given that one of the national adviser’s specified roles is to improve healthcare professionals’ awareness of LGBT issues, will the Minister update us on what plans the Government have to improve and enhance ongoing training on these issues so that services are inclusive?

The Committee also recommended that the Government should consult on ways in which effective knowledge and understanding of unacceptable discriminatory practices and the Equality Act 2010 could be ensured among the highest range of health providers. Again, will the Minister advise the House whether there has been any progress on that?

Finally, the report made several recommendations regarding the importance of leadership on this issue from the Department of Health and Social Care and NHS England. It is clear that if we are to see the improvements that we need, all local health and social care organisations must actively consider the needs of their LGBT women, as required by the public sector equality duty. I support the Committee’s recommendations that this should be mandated directly from the Department and NHS England as part of commissioning requirements and as a prerequisite for receiving funding. As the hon. Member for Reigate said, the Department and NHS England should work together to create an inclusive commissioning toolkit that health commissioners can use to spread best practice in commissioning inclusive services, and any bids found to be lacking should be passed on to the EHRC for enforcement action.

I also agree with the Committee and the hon. Member that we need joined-up working across the whole of Government. As we know, the Government Equalities Office has the lead on the LGBT issues and the action plan, which includes healthcare, but it is separate from and not included in the NHS long-term plan. This issue was raised in the other place last week, but the response was not particularly helpful. Does the Minister agree that the response implied that all responsibility for LGBT healthcare lay with the GEO and that this is something we need to reconsider?

The Committee also recommends that NHS England and the GEO work together to produce the next LGBT action plan update and be a signatory to it. Will the Government take forward that very practical and sensible recommendation? On leadership, can the Minister provide any assurances that there will be continued funding for the national advisor for LGBT health beyond the end of this month, as they are needed to drive forward the inclusion agenda throughout health and social care? It would be a welcome signal from the Government that they are determined to give this issue the importance it deserves.