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LGBT+ Mental Health: Understanding disparities and meeting mental health needs



LGBT+ Mental Health: Understanding disparities and meeting mental health needs
LGBT+ Mental Health:
Understanding disparities and
meeting mental health needs
Dr Joanna Semlyen PhD, CPsychol, AFBPsS, SFHEA
HCPC Registered Health Psychologist
Senior Lecturer in Psychology and Medical Education, University of East Anglia
Lead on analysis of UK LGBT+
population health outcomes
Cigarette smoking and hazardous alcohol use in LGB
Common mental disorder in LGB
Obesity/overweight - body mass index (BMI) in LGB
*Population data available only on sexual identity as no
national survey data available for gender identity
Joanna Semlyen July 23 2019, Westminster Forum
Numbers of LGBT+
Modelled estimate by Public Health England 2017. Based on all
recorded responses to UK surveys - a range of between 0.9%-
5.52% LGBO, present weighted estimate of 2.5%
In representative national health surveys where sexual orientation is
measured, around 3% select a sexual orientation identity other than
heterosexual (Semlyen et al 2016)
Depends on
how asked (ftf, online, written)
anonymous online survey 5.7% (Ellison and Gunstone, 2009)
how worded (attraction, behaviour, identity)
Higher when behaviour/attraction
Joanna Semlyen July 23 2019, Westminster Forum
Research evidence: UK
Majority UK LGBT+ mental health research - lower quality ‘convenience samples’
Studies that compare LGBT+ to heterosexuals from a representative population sample
offer significantly increased evidence quality
Recent improved evidence base - few longitudinal cohort studies and population health
cross sectional surveys include the Office for National Statistics question on sexual
Which of the following options best describes how you think of yourself?
Response options were ‘Heterosexual or Straight’, ‘Gay or Lesbian’, ‘Bisexual’,
‘Other’, or refusal
Small # of respondents
Data pooling
No Gender Identity question so no population data on health inequalities for
trans/nonbinary people.
Joanna Semlyen July 23 2019, Westminster Forum
Poorer mental health in LGBT+
Recent secondary analysis showed
increased common mental disorder in UK
LGB population Semlyen et al 2016
Lesbian/Gay > mental health disorder than
under 35 (OR = 2.06, 95 % CI 1.60, 2.66),
non significant at age 35–54.9 (OR = 1.03,
95 % CI 0.71, 1.48), but
strongest at age 55+ (OR = 2.11, 95 % CI
1.16, 3.83).
Bisexual > mental health disorder than
Heterosexuals (and LG).
under 35 age group (OR = 2.31, 95 % CI
1.83, 2.90),
age 35 to 54.9 (OR = 1.80, 95 % CI 1.29,
strongest at age 55+ (2.45, 95 % CI 1.58,
Joanna Semlyen July 23 2019, Westminster Forum
Poorer mental health in LGBT+
Recent meta analysis showed increased
prevalence of mental health in LGB
compared to heterosexual King, Semlyen
et al., 2008
Suicide attempts lifetime OR x 2 (x 5 men)
Suicide attempts last 12 month OR x 2-3
Suicidal ideation lifetime OR x 2
Suicidal ideation last 12 months OR x 2 (x
2-3 women)
Depression last 12 months OR x 2-3
Anxiety last 12 months OR x 1.7
Alcohol dependence last 12 months OR x
1.5 (x 4 women)
Drug dependence last 12 months OR x 3
Joanna Semlyen July 23 2019, Westminster Forum
Poorer mental health in LGBT+
Higher rates of low well being
Higher rates of substance misuse
Higher rates of suicide and self
Higher rates of eating disorders
Higher rates of depression and
Higher rates of self reported long
standing psychological problems
Poorer mental health in trans and
nonbinary (TGNB)
Higher rates of suicide and self
Higher rates of depression and
Higher rates of eating disorders
Long waiting times adversely
effect mental health in TGNB
E.g. 4 times higher in waiting
lists sample
Joanna Semlyen July 23 2019, Westminster Forum
Mental health service use
LGB people seek to and/or access mental health services
more frequently than heterosexuals
Mental health services were accessed by 24% of the 108,000
respondents to the UK Government’s LGBT survey
Joanna Semlyen July 23 2019, Westminster Forum
Mental health service use in LGBT +
Recent systematic review provides
understanding of mental health service use
in LGBT King, Semlyen et al., 2007
Therapy/ists make heterosexual
(heteronormative) assumptions
LGB have more episodes of therapy and
greater number of sessions than non-LGB
LGB seek counselling/therapy more than
LGBT concerns about safety
Preferences for LGBT therapist
LGBT therapist knowledge
Misattribution of problem to LGBT identity
Joanna Semlyen July 23 2019, Westminster Forum
Risk and protective factors for
mental health in LGBT
Causal pathways not demonstrated but likely minority stress
Linked to discrimination and homophobia
Exacerbated by structural inequalities experienced across a wide range of
contexts including education, home and family, and health services (primary
and secondary care)
Fear of disclosure
Hiding parts of their lives from staff
Lacking a sense of belonging
Need to feel safe and to trust service providers
Negative staff attitudes and behaviours are main barrier for accessing
Joanna Semlyen July 23 2019, Westminster Forum
Recommendations training
and practice
Interventions to address discrimination, increase resilience
and reduce impact on LGBT+
Draw on LGBT+ people’s own expertise
Adopt LGBT+ community led services more trusted
Training for heath care professionals and teaching for
should not be optional or tokenistic but be embedded and
No one off ‘diversity’ session as a tick box.
Joanna Semlyen July 23 2019, Westminster Forum
Recommendations - services
An understanding of the prevalence of mental health issues, as well as
the importance of making sensitive enquiry, avoiding assumptions, and
using inclusive language.
Always consider sexual orientation and gender identity as part of the
diverse population of service users
Avoid language that excludes or makes assumptions. And if you don’t
know ask!
Promoting mental health for LGBT people in publicity and positive
Counselling and psychotherapy treatments should not use ‘anti-LGBT
reparative’ therapies. Guidelines for LGBT affirmative therapy
Joanna Semlyen July 23 2019, Westminster Forum
Recommendations size of
Make every attempt to capture accurate LGBT+ population
size by including SO and GI questions in the 2021 Census.
Suggest campaign to encourage LGBT people to feel safe
and comfortable to disclose identity in Census 2021.
Suggest options for collecting Census 2021 data including
internet access.
Joanna Semlyen July 23 2019, Westminster Forum
Recommendations - evidence
Increase LGBT+ health evidence base - quality (datasets
that are representative), research on trans and non binary
populations, greater research on intersectionality in LGBT+
Include SOGI in all health population studies including
longitudinal data to allow causal pathways to be explored
Mandatory monitoring of sexual orientation and gender
identity data across health and social care settings.
Recording of sexual orientation identity is necessary to
comply with Equalities Act, 2010
Joanna Semlyen July 23 2019, Westminster Forum
King, M., Semlyen, J., Tai, S. S., Killaspy, H., Osborn, D., Popelyuk, D., & Nazareth, I. (2008). A systematic review of mental disorder, suicide,
and deliberate self harm in lesbian, gay and bisexual people. BMC psychiatry, 8(1), 70.
Hagger-Johnson G, Taibjee R, Semlyen J, Fitchie I, Fish J, Meads C, et al. (2013) Sexual orientation identity in relation to smoking history and
alcohol use at age 18/19: cross-sectional associations from the Longitudinal Study of Young People in England (LSYPE). BMJ Open.
Ellis, S. J., Bailey, L., & McNeil, J. (2015). Trans people's experiences of mental health and gender identity services: A UK study. Journal of Gay
& Lesbian Mental Health, 19(1), 4-20.
Semlyen, J. (2015). Health psychology. In The Palgrave Handbook of the Psychology of Sexuality and Gender (pp. 300-315). Palgrave
Macmillan, London.
Semlyen J, King M, Varney J, Hagger-Johnson G. Sexual Orientation and Symptoms of Common Mental Disorder or Low Wellbeing: Combined
Meta-Analysis of 12 UK Population Health Surveys. BMC Psychiatry. 2016; 16:67.
HulbertWilliams, N. J., Plumpton, C. O., Flowers, P., McHugh, R., Neal, R. D., Semlyen, J., & Storey, L. (2017). The cancer care experiences of
gay, lesbian and bisexual patients: A secondary analysis of data from the UK Cancer Patient Experience Survey. European journal of cancer
care, 26(4), e12670.
Semlyen J. Recording Sexual Orientation in the UK: Pooling Data for Statistical Power. American Journal of Public Health. 2017; 107:1215-7.
Semlyen, J., Ali, A., & Flowers, P. (2017). Intersectional identities and dilemmas in interactions with healthcare professionals: an interpretative
phenomenological analysis of British Muslim gay men. Culture, health & sexuality, 1-13.
Semlyen (2018) LGBT health inequalities. Select committee written evidence
Semlyen J. et al (2019) Sexual orientation identity in relation to unhealthy Body Mass Index (BMI): Individual Participant Meta-Analysis of 93,429
individuals from 12 UK health surveys
Semlyen (2019) LGBT health inequalities. Select committee oral evidence
Joanna Semlyen July 23 2019, Westminster Forum
Thank you
Twitter: @Dr_Jo_S
Joanna Semlyen July 23 2019, Westminster Forum
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
Background Lesbian, gay and bisexual adults are more likely than heterosexual adults to experience worse health outcomes. Despite increasing public health interest in the importance of maintaining a healthy body weight, no study has considered sexual orientation identity (SOI) and unhealthy BMI categories among adults in the UK population. Methods Individual participant data meta-analysis using pooled data from population health surveys reporting on 93 429 adults with data on SOI, BMI and study covariates. Results Adjusting for covariates and allowing for between-study variation, women identifying as lesbian (OR = 1.41, 95% CI: 1.16, 1.72) or bisexual (OR = 1.24, 95% CI: 1.03, 1.48) were at increased risk of overweight/obesity compared to heterosexual women, but men identifying as gay were at decreased risk (OR = 0.72, 95% CI: 0.61, 0.85) compared to heterosexual men. Increased risk of being underweight was seen for women identifying as ‘other’ (OR = 1.95, 95% CI: 1.07, 3.56), and men identifying as gay (OR = 3.12, 95% CI: 1.83, 5.38), bisexual (OR = 2.30, 95% CI: 1.17, 4.52), ‘other’ (OR = 3.95, 95% CI: 1.85, 8.42). Conclusions The emerging picture of health disparities in this population, along with well documented discrimination, indicate that sexual orientation should be considered as a social determinant of health.
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Individual interviews were conducted with six self-identified Muslim gay men living in London focusing on their experience of health service use. Transcripts were analysed using interpretative phenomenological analysis. Analysis identified two major themes: the close(d) community and self-management with healthcare professionals, detailing participants’ concerns regarding the risks of disclosing sexuality; and the authentic identity – ‘you’re either a Muslim or you’re gay, you can’t be both’ – which delineated notions of incommensurate identity. Analysis highlights the need for health practitioners to have insight into the complexity of intersectional identities, identity disclosure dynamics and the negative consequences of assumptions made, be these heteronormative or faith-related.
Full-text available
We know that sexual minority health disparities exist, but in the United Kingdom, the research demonstrating disparities in sexualminority health has been dominated by small convenience samples that do not represent clearly defined populations. Recently, UK population health surveys began to include a question on sexual orientation identity that makes available high-quality data. However, very few studies collect sexual orientation within their demographic data.1 There need to be more, as it is this important, high-quality evidence that can be used to make a political impact and determine policy change.
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Understanding the effects of population diversity on cancer-related experiences is a priority in oncology care. Previous research demonstrates inequalities arising from variation in age, gender and ethnicity. Inequalities and sexual orientation remain underexplored. Here, we report, for the first time in the UK, a quantitative secondary analysis of the 2013 UK National Cancer Patient Experience Survey which contains 70 questions on specific aspects of care, and six on overall care experiences. 68,737 individuals responded, of whom 0.8% identified as lesbian, gay or bisexual. Controlling for age, gender and concurrent mental health comorbidity, logistic regression models applying post-estimate probability Wald tests explored response differences between heterosexual, bisexual and lesbian/gay respondents. Significant differences were found for 16 questions relating to: (1) a lack of patient-centred care and involvement in decision-making, (2) a need for health professional training and revision of information resources to negate the effects of heteronormativity and (3) evidence of substantial social isolation through cancer. These findings suggest a pattern of inequality, with less positive cancer experiences reported by lesbian, gay and (especially) bisexual respondents. Poor patient-professional communication and heteronormativity in the healthcare setting potentially explain many of the differences found. Social isolation is problematic for this group and warrants further exploration.
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Abstract Background: Lesbian, gay and bisexual (LGB) people may be at higher risk of mental disorders than heterosexual people. Method: We conducted a systematic review and meta-analysis of the prevalence of mental disorder, substance misuse, suicide, suicidal ideation and deliberate self harm in LGB people. We searched Medline, Embase, PsycInfo, Cinahl, the Cochrane Library Database, the Web of Knowledge, the Applied Social Sciences Index and Abstracts, the International Bibliography of the Social Sciences, Sociological Abstracts, the Campbell Collaboration and grey literature databases for articles published January 1966 to April 2005. We also used Google and Google Scholar and contacted authors where necessary. We searched all terms related to homosexual, lesbian and bisexual people and all terms related to mental disorders, suicide, and deliberate self harm. We included papers on population based studies which contained concurrent heterosexual comparison groups and valid definition of sexual orientation and mental health outcomes Results: Of 13706 papers identified, 476 were initially selected and 28 (25 studies) met inclusion criteria. Only one study met all our four quality criteria and seven met three of these criteria. Data was extracted on 214,344 heterosexual and 11,971 non heterosexual people. Meta-analyses revealed a two fold excess in suicide attempts in lesbian, gay and bisexual people [pooled risk ratio for lifetime risk 2.47 (CI 1.87, 3.28)]. The risk for depression and anxiety disorders (over a period of 12 months or a lifetime) on meta-analyses were at least 1.5 times higher in lesbian, gay and bisexual people (RR range 1.54-2.58) and alcohol and other substance dependence over 12 months was also 1.5 times higher (RR range 1.51-4.00). Results were similar in both sexes but meta analyses revealed that lesbian and bisexual women were particularly at risk of substance dependence (alcohol 12 months: RR 4.00, CI 2.85, 5.61; drug dependence: RR 3.50, CI 1.87, 6.53; any substance use disorder RR 3.42, CI 1.97-5.92), while lifetime prevalence of suicide attempt was especially high in gay and bisexual men (RR 4.28, CI 2.32, 7.88). Conclusions: LGB people are at higher risk of mental disorder, suicidal ideation, substance misuse, and deliberate self harm than heterosexual people.
Full-text available
Background Previous studies have indicated increased risk of mental disorder symptoms, suicide and substance misuse in lesbian, gay and bisexual (LGB) adults, compared to heterosexual adults. Our aims were to determine an estimate of the association between sexual orientation identity and poor mental health and wellbeing among adults from 12 population surveys in the UK, and to consider whether effects differed for specific subgroups of the population. Methods Individual data were pooled from the British Cohort Study 2012, Health Survey for England 2011, 2012 and 2013, Scottish Health Survey 2008 to 2013, Longitudinal Study of Young People in England 2009/10 and Understanding Society 2011/12. Individual participant meta-analysis was used to pool estimates from each study, allowing for between-study variation. ResultsOf 94,818 participants, 1.1 % identified as lesbian/gay, 0.9 % as bisexual, 0.8 % as ‘other’ and 97.2 % as heterosexual. Adjusting for a range of covariates, adults who identified as lesbian/gay had higher prevalence of common mental disorder when compared to heterosexuals, but the association was different in different age groups: apparent for those under 35 (OR = 1.78, 95 % CI 1.40, 2.26), weaker at age 35–54.9 (OR = 1.42, 95 % CI 1.10, 1.84), but strongest at age 55+ (OR = 2.06, 95 % CI 1.29, 3.31). These effects were stronger for bisexual adults, similar for those identifying as ‘other’, and similar for 'low wellbeing'. Conclusions In the UK, LGB adults have higher prevalence of poor mental health and low wellbeing when compared to heterosexuals, particularly younger and older LGB adults. Sexual orientation identity should be measured routinely in all health studies and in administrative data in the UK in order to influence national and local policy development and service delivery. These results reiterate the need for local government, NHS providers and public health policy makers to consider how to address inequalities in mental health among these minority groups.
Full-text available
Information about the health behaviours of minority groups is essential for addressing health inequalities. We evaluated the association among lesbian, gay or bisexual (LGB) sexual orientation identity and smoking and alcohol use in young people in England. Data drawn from wave 6 of the Longitudinal Study of Young People in England (LSYPE). Self-completion questionnaires during home visits, face-to-face interviews and web-based questionnaires. Data from 7698 participants (3762 men) with information on sexual orientation identity and health behaviours at age 18/19. Cigarette smoking history, alcohol drinking frequency and risky single occasion drinking (RSOD). LGB identity was reported by 3.1% of participants (55 gay, 33 lesbian, 35 bisexual male, 111 bisexual female), 3.5% when adjusting for the survey design. Adjusting for a range of covariates, identification as lesbian/gay was found to be associated with smoking (OR=2.23, 95% CI 1.42 to 3.51), alcohol drinking >2 days/week (OR=1.99, 95% CI 1.25 to 3.17) and RSOD (OR=1.80, 95% CI 1.13 to 2.86) more than weekly. Bisexual identity was associated with smoking history (OR=1.84, 95% CI 1.30 to 2.61) but not alcohol drinking >2 days/week (OR=1.20, 95% CI 0.79 to 1.81) or RSOD (OR=1.04, 95% CI 0.71 to 2.86). In a sample of more than 7600 young people aged 18/19 years in England, lesbian/gay identity is associated with cigarette smoking, drinking alcohol frequency and RSOD. Bisexual identity is associated with smoking but not RSOD or frequent alcohol drinking.
Drawing on survey data from a UK study of trans people and mental health, the study presented here reports on the experiences of trans people in two health care settings: mental health services and gender identity clinics. An analysis of the primarily qualitative data indicates that in these settings practitioners tend to be poorly informed about trans issues and the realities of trans people's lives. The key observations of this study are that untreated gender dysphoria (due to delays or refusals of treatment), unnecessary and intrusive questioning/tests, prejudicial attitudes by service providers, and restrictive treatment pathways, all contribute to minority stress which is detrimental to the mental health and well-being of trans people.
LGBT health inequalities
  • Semlyen
Semlyen (2018) LGBT health inequalities. Select committee written evidence