18.As well as analysis of data on health outcomes, another way of evaluating whether the health and social care system is working for LGBT people is through information on whether the services are being used and what attitudes towards these services among their users are. We received a lot of information about LGBT people’s experiences of using the health system, both from submissions to the inquiry and from the national LGBT Survey. We also heard about the attitudes that health and social care professionals have towards LGBT service-users, some of which were concerning.
19.In July 2017, the Government conducted what it described as “the largest national survey of LGBT people in the world”.31 Over 108,000 LGBT people took part and the Government released the results of the Survey in July 2018. The health section of the survey found that 13 per cent of cisgender LGB people and 40 per cent of transgender people had had a negative experience with healthcare in the 12 months preceding the survey. These negative experiences included inappropriate curiosity, having their specific needs ignored and avoiding treatment for fear of having a negative reaction. While most LGBT people were happy to disclose their sexual orientation or gender identity with healthcare staff, 9 per cent said that it had a negative effect on their treatment, rising to 26 per cent among asexual people. Trans respondents were almost twice as likely to say that they had experienced negative treatment from coming out to their healthcare practitioner.32 As discussed above, respondents to the survey spoke of the overwhelming assumption by healthcare staff that they were heterosexual and cisgender.
20.The results of the LGBT Survey were analysed by the Government Equalities Office and resulted in the LGBT Action Plan, published in July 2018. The Government stated that:
With over 75 commitments, the cross-Government plan sets out how we will improve the lives of LGBT people over the course of this Parliament.33
The Action Plan is discussed in Chapter 3.
21.Much of the evidence that we heard during this inquiry echoes the results of the National LGBT Survey and points to parts of the health and social care systems that are not catering effectively to LGBT communities, whether intentionally or not. This can lead to LGBT people opting out of services for fear of poor treatment.
22.Some discrimination is clear and direct and consists of one individual discriminating against another. A woman who attended our outreach event, for instance, was told by medical staff:
They don’t want to treat people like me, I was told how much money was spent on me and told that NHS money shouldn’t be spent on me.
23.Some of this discrimination can take the form of signs and symbols that LGBT people may interpret as hostile. The fear that this instils in LGBT individuals seeking healthcare was encapsulated in a quote from a gay man, as reported by Healthwatch Suffolk:
My GP has bibles in the waiting room and a large sign in his consulting room inviting patients to ‘Pray with me if it’s bad news’ As a gay man I feel very anxious my doctor is a practising Christian. I feel inhibited and frightened to discuss health issues concerned with my sexuality.34
24.In many cases discrimination is less direct and relates to structures of health and social care systems that assume that everyone is heterosexual and cisgender. For instance, we heard that lesbian and bisexual women are much less likely to attend cervical screening than straight women. FPA, a sexual health organisation, told us that many women who have sex with women exclusively have been told by professionals that they do not need to be screened35 despite clear advice from Public Health England that all women aged 25–49 should be screened.36 In addition, trans men who still have a cervix are also advised by PHE to attend cervical screening,37 but are removed from the screening invitation list automatically by the computer system if they are registered with their GP as men.38 In this case, it is the design of the NHS system that is excluding people rather than any individual. Systemic institutional issues such as these are inherently discriminatory and may be the cause of unintended poorer health outcomes.
25.As discussed above, it is not acceptable for LGBT people to be forced to adapt to a health and social care structure that assumes them to be cisgender and straight. Both health and social systems and health and social care professionals must respect the gender identity and sexual orientation of their service-users. We were told again and again by witnesses that many mainstream services were not considering LGBT people and were discriminating against them, albeit unintentionally, by treating them as “the same” as their non-LGBT counterparts.39 This attitude was expressed to us succinctly by Debbie Ivanova of the CQC, who quoted care homes that she had inspected:
“Person-centred care means everybody is treated the same or equally, and we meet everybody’s needs because we treat everybody the same”. That does not address the issues when people maybe do not fall into a heteronormative setting. We have to fight that assumption and get on to really making sure that people are confident with difference. That includes our staff too, in the way they inspect.40
26.One problem is that frontline staff do not consider sexual orientation and gender identity to be relevant to an individual’s care. This is especially true in social care;. Stonewall has reported that 72 per cent of care workers did not consider sexual orientation to be relevant to one’s health needs.41
Figure 1: Practitioners who say they do not consider sexual orientation to be relevant to one’s health needs
27.Dr Ju Gosling of Regard, an organisation of LGBT disabled people, agreed with this and added that:
My partner got a letter saying, “‘Home from hospital’ will be taking over your care on Monday; it will be delivering services regardless of your sexual and gender orientation”. We believe that practice should be stamped out. It is not appropriate to the Equality Act at all to say, “We will deliver a service regardless”. The Care Act states it has to be personalised, and so does the Equality Act.42
28.The evidence we heard suggests that most health and social care professionals feel under-equipped to deal with LGBT people’s needs rather than intentionally discriminating.43 Staff may be struggling to communicate effectively with LGBT people or to understand how sexual orientation and gender identity are important to person-centred care. Some also simply do not feel confident with specialist needs, such as gender identity pathways.44 Sophie Meagher from the LGBT Foundation remarked on this lack of confidence, saying:
I think the main problem comes when healthcare professionals don’t understand that LGBT people might have specific needs, and they don’t understand that they might need different treatment. There is also a lack of evidence on the specific needs of LGBT people.45
29.There are a number of reasons why health and social care providers may be under-equipped to support LGBT people. Much of this is to do with training, a topic which is explored further in Chapter 5. However, there is also a lack of understanding of the differences that exist between LGBT people and non-LGBT people (and between communities under the LGBT umbrella) and how best to tackle them. Birmingham LGBT, an LGBT charity, listed potential barriers:
Discrimination is caused by a number of factors, including unconscious bias; stereotypical and prejudicial attitudes of staff; lack of specialist, cultural competence skills-based training; religious beliefs; cultural homophobia; lack of inclusive policies and procedures. All of these issues need to be addressed in order to create LGBT affirmative services.46
30.As Wendy Irwin from the Royal College of Nursing told us:
I genuinely don’t believe that the vast majority of nurses and healthcare support workers get up and go to a shift with the intention of deliberately discriminating against LGBT communities. What they may well experience is the impact of unconscious bias—those heteronormative assumptions.47
There are a number of ways in which these issues may be tackled, in order to provide the truly person-centred care that the NHS and social care sectors aspire to. These are explored in Chapter 4.
31 Government Equalities Office, ‘National LGBT Survey: Research report’, accessed 19 September 2019
32 Government Equalities Office, National LGBT Survey (July 2018), p162
33 Government Equalities Office, LGBT Action Plan (July 2018), p 2
36 NHS Cancer Screening Programmes, NHS Cervical Screening Programme Cervical screening for lesbian and bisexual women (September 2009), p 2
37 Public Health England, Information for trans and non-binary people NHS Screening Programmes (July 2017), pp 11–15
39 Q109, Q129
41 Stonewall, Unhealthy Attitudes (2015), p 15
43 University of Bristol (HSC0036), Compassion in Dying (HSC0011), Dr Justin Varney (HSC0013), Encompass Network (HSC0059), NAT (National AIDS Trust) (HSC0060), Opening Doors London (HSC0025),
Published: 22 October 2019