Written submission from the LGBT Foundation (MHM0031)

Executive summary

This response outlines evidence, recommendations and best practice surrounding the mental health of specifically gay, bisexual and trans (GBT) men and boys.

This response is set out in the following way:

1. Key statistics on mental health of GBT men and boys.
2. Experiences of GBT men.
3. Experiences of mental health services.
4. Examples of best practice and recommendations.
5. Action surrounding government action, policy and proposals.
6. Sexual orientation and trans status monitoring

About LGBT Foundation

LGBT Foundation is a national charity delivering advice, support and information services to lesbian, gay, bisexual and trans (LGBT) communities. With a history dating back to 1975, we campaign for a fair and equal society where all LGBT people can achieve their full potential. We serve over 40,000 people each year and provide online information to over 365,000 people.

We provide a range of services aimed at improving the mental health of GBT men. We have a men’s programme and a trans programme, we provide counselling, substance misuse support and housing support for those who have experienced domestic abuse.

1. Key Statistics on Mental Health of GBT Men and Boys

There is a range of evidence to suggest that GBT men and boys have poorer mental health compared to the wider population.

1.1 Evidence

• In 2012 22% of gay and bisexual men were experiencing moderate to severe levels of depression. This figure rises to 26% for bisexual men. [1]

• In 2012 3% of gay men and 5% of bisexual men attempted to take their own life in the previous year. This compares to just 0.4% of men in general over the same time period. [2]

• 51% of GBT boys (aged 11-19) have self-harmed, compared to 1 in 10 young people in the wider population who have self-harmed. 71% of GBT boys have thought about taking their own life and 24% have tried to take their own life.[3]

• The National LGBT Survey 2017 found that just 15.5% of men said they were very comfortable being LGBT in the UK.

• In the National LGBT survey trans men gave an average life satisfaction rate of 5.07, this compares to 5.52 for trans women, 6.48 for all LGBT respondents and 7.66 for the UK population.

1.2 Body Image and Eating Disorders

Despite perceptions that the vast majority of people with eating disorders are female, in reality 25% of all eating disorder cases are men.[4]

GBT men are more likely to have an eating disorder compared to men in general.[5]

• 13% of GB men have had a problem with their weight or eating in the last year compared 4% of men in general.[6]

• 37% of LGB respondents said they would not feel confident seeking help with an eating disorder, compared to 24% of heterosexual people.[7]

1.3 Minority Groups

Minority groups within LGBT communities such as Black, Asian and Minority Ethnic (BAME) people, older people and disabled people often have poorer mental health outcomes.

BAME GBT Men and Boys 

• 76% of gay and bisexual (GB) BAME boys have thought about taking their own life compared to 56% of white GB boys.[8]

• 1 in 12 GB BAME people harmed themselves in the last year.

• 5% of GB BAME men attempted to take their own life in the last year.

Older GBT Men

Many older GBT men grew up in a world far more hostile towards their identities compared with today. These experiences can have a long term implications on mental health.[9]

Among men over 55:[10]

• 29% of GB men have been diagnosed with anxiety, compared to 13% of heterosexual men. 34% of GB men have been diagnosed with depression, compared to 17% of heterosexual men.

• Loneliness and isolation is a problem for GBT men, 40% of GB men are single and 41% live alone, compared to 15% of heterosexual men who are single and 28% who live alone.

Among LGBT people over 55, 57% have confidence in mental health services, compared to 67% of heterosexual people.[11]

2. Experiences of GBT Men 

GBT men and boys face discrimination, stigmatisation, bullying and abuse. Although it is impossible to outline all causes of poor mental health in GBT men and boys, the following are a number of factors that can contribute towards poor mental health.

2.1 Domestic Abuse

• 12% of bisexual men, 7% of gay men and 21% of trans men have faced domestic abuse from a partner in the last year, this compares to 3% of men in the general population.[12]

• 2 in 3 people who accessed LGBT Foundation’s Domestic Abuse Service were men, demonstrating a lack of mainstream support for GBT men experiencing domestic abuse.

2.2 Hate crime

GBT men still face hate crime both online and outside of the home:

• The National LGBT Survey 2017 found that in the previous 12 months 34.7% of trans men had experienced verbal harassment as a result of being GBT from someone they don’t live with in the last 12 months. This figure is 26.5% for gay and bisexual men.[13]

• Stonewall’s Hate Crime report found that 19% of gay men and 16% of bi men experienced a hate crime or incident in the last year due to their sexual orientation. [14]

• 10% of GBT men have been the direct target of homophobic, biphobia and transphobic online abuse in the last month.[15]

2.3 Young men and boys in Education

Homophobic, biphobic and transphobic bullying is still a significant problem in education and can cause poor mental health.

• Stonewall’s School Report, found that 57% of GBT boys are bullied for being LGBT, this compares to 35% of LGBT girls. Furthermore 12% of GBT boys experience physical bullying, compared to 4% of LGBT girls.[16]

• Stonewall found that 46% of gay pupils who experience homophobic bullying have symptoms consistent with depression, this figure is 35% for gay young people who are not experiencing bullying.[17]

‘I’ve been suffering from depression due to bullying since I was 15. I’ve been on prescribed medication since then and still feel that there is little help out there.’ Charlie 22, London.[18]

For many this bullying continues at university:

• 60% of trans students and over 22% of LGB students who aren't trans have been the target of negative comments or conduct from other students.

• 13% of men wouldn’t feel confident reporting homophobic or biphobic bullying to university staff. [19]

‘When going on a night out at the student union at university, I often receive very dirty looks about my appearance … I have been called faggot or poof at this place… I believe it's because of lad culture from the sporting societies.’ Constantine, 19.[20]

There is not adequate support for LGBT pupils in schools:

• 53% of pupils said that there is not an adult at school that they can talk to about being LGBT. [21]

• 45% of LGBT pupils who experience bullying based on their sexual orientation or trans status never tell anyone about it, with 39% of these people saying it was because they believed teachers would not do anything about it.

There is also a lack of LGBT inclusive relationship and sex education (RSE):

• Just 4 in 5 LGBT young people were not taught about LGBT sex and relationships in school. 3 in 4 have never been taught about or discussed gender identity and what ‘trans’ means at school.[22]

• In schools where pupils are taught about LGBT issues pupils are less likely to experience homophobic, biphobic and transphobic bullying (43% compared to 49%).[23]

2.4 Young people at home

• Just 40% of LGBT young people have an adult at home they can talk to about being LGBT.[24]

• 24% of homeless young people identify as LGBT, 77% believe coming out to their parents was the main factor.[25]

‘Since I can’t come out at home I can’t talk to them about the problems at school. I’m afraid that if I make one wrong move I will end up outing myself to everyone.’ Dale, 13, private faith secondary school.[26]

2.5 Workplace

Many GBT men experience homophobia, biphobia and transphobia in the workplace and when seeking employment.

The National LGBT Survey found that:

• 8.8% of GBT men had experienced verbal harassment in the last 12 months in the workplace as a result of being LGBT. This figure rises to 15.4% for trans men.

• 9.9% of men had someone disclose they were GBT without their permission and 20.3% had received at least one negative reaction in the workplace due to being GBT.

The Stonewall work report found that:[27]

• 49% of bi men and 7% of gay men are not out at work.

• 18% who were looking for work said they were discriminated against because of being LGBT while trying to get a job in the last year.

‘In my workplace…it is very much a "boys club" that perpetuates lad culture... One gay man was repeatedly singled out, but any claim of discrimination was rebuked as "he just can't take banter". Donna, 22[28]

2.6 Substance misuse

GBT men are more likely to misuse substances compared to the general population, something that can contribute towards poor mental health:

• Gay and bisexual men were three times as likely to use drugs in the last year compared to heterosexual men. [29]

• GB men are also more likely to use drugs compared to lesbian and bisexual women.[30]

3. Services

3.1 Experiences of Mental Health Services

The 2017 National LGBT Survey found that 17.4% of GBT men had accessed mental health services in the previous 12 months.

Of those who had accessed mental health services, 15.9% had a completely positive experience and 42.9% had a mainly positive experience. 14.1% had a mainly negative experience and 4.7% had a completely negative experience.

Of those who had accessed or tried to access mental health services, 31.5% said they did not have any difficulty. However 46.7% said they had to wait too long to access the services, 22.8% said they were worried, anxious or embarrassed about going, 12.6% didn’t know where to go and 12.5% said their GPs were not supportive.

3.2 Awareness of LGBT Issues among Healthcare Staff

There is a lack of awareness of LGBT issues among healthcare professionals. 51% of mental health workers, counsellors, psychologists and psychotherapists say they do not consider sexual orientation to be relevant to one's health needs.[31] However due to the fact LGBT people face a range of health inequalities, including poorer mental health, the relevance of sexual orientation and trans status need to be understood by healthcare professionals in order to promote equity in healthcare. 

4. Best Practice and Recommendations

This evidence demonstrates that there is still a way to go in improving the mental health of GBT men and boys.

LGBT Foundation offers a wide range of services which aim to increase the wellbeing of gay, bisexual and trans men. We also work with primary care services to improve the experiences of LGBT people accessing healthcare. The success of these services can be used as example of best practice and, alongside existing research on the experiences of GBT men, can contribute towards producing evidence based recommendations.

4.1 Pride in Practice

Pride in Practice is LGBT Foundation’s quality assurance and social prescribing programme for primary care services and LGBT communities. It develops and strengthens relationships between clinicians and patients, and enables primary care services to link with community assets and utilise strength based approaches to community healthcare delivery. In 2017-18 the service trained 1680 professionals on LGBT issues and health care needs. As a result of this training, attendees reported 99.2% satisfaction, with 99.8% reporting a greater understanding of LGBT issues.

Recommendations

The Pride in Practice programme should be implemented across the country with the aim of making all primary healthcare services more LGBT inclusive and accessible.

Additionally, all those working in mental health services should undertake specialist LGBT inclusion training to ensure they can provide person-centred care for LGBT people.

Pride in Practice promotes better LGBT visibility in health services. 62% of LGBT people mentioned the importance of improving LGBT visibility in healthcare, for example having a Pride in Practice award displayed. [32] This is something that mental health services need to act on to improve the experiences of GBT men accessing these services. LGBT Foundation’s Greater Manchester Action Plan promotes a range of initiatives that can be adopted by health and social care services to improve LGBT visibility.[33]

4.2 Talking Therapies

LGBT Foundation has been providing Talking Therapies services to LGBT communities in Greater Manchester for over a decade including the country’s only LGBT specific Improving Access to Psychological Therapies (IAPT) Service. Our counselling service offers free access to LGBT affirmative therapy and counselling with an LGBT specialist therapist (https://lgbt.foundation/talkingtherapies).

GBT men accessing these services are often experiencing significant problems with poor mental health:

• Over the past year, 53% of the men entering our counselling service presented with moderately severe or severe levels of depression at the point of assessment.
• 39% of men entering our counselling service have presented with severe levels of anxiety, the highest category as stated by the GAD7 scale.

For many, accessing these services has led to significant improvements in mental health. In 2015 81% of people who accessed our counselling services reported an improvement in their mental health.

Recommendations

LGBT Foundation’s work demonstrates the effectiveness of counselling for GBT men. In order to reduce mental health inequalities, funding and provisions should be increased in order to allow all LGBT people who require counselling to be able to quickly access relevant services.

The success of our counselling services and the fact that 46.7% of GBT men had to wait too long to access services[34] demonstrates the necessity of current plans to continue to expand access to IAPT services so that by 2023/24, an additional 380,000 adults and older adults will be able to access IAPT services (NHS Long Term Plan).

4.3 LGBT Foundation Men’s Programme

This programme provides safe and affirmative spaces for GBT men. The programme runs sessions and workshops that cover a range of topics from wellbeing and mindfulness to sex and pleasure, improving the skills and knowledge of GBT men as well as giving them the opportunity to meet other members of their community.

Since 2018 108 men have accessed the programme and 100% of participants have reported improved wellbeing as a result of attending events. Participants have described the service as a ‘life saver’ and another said they are ‘glad that there are social events for men, as they are sorely missing’.

Recommendations

The positive impact of the Men’s Programme demonstrates the benefit of specific services provided by the Voluntary and Community Sector. This reinforces the need for the government to continue to commission and partner with the VCS. The NHS has recognised this in the Long Term Plan which committed to the continuation of NHS work with local charities and community interest companies that provide services to vulnerable groups.

5. Action surrounding government action, policy and proposals.

Current plans to improve mental health are welcomed, however at times these plans need to go further.

5.1 NHS Long Term Plan

The renewed commitment to grow investment in mental health services faster than the NHS budget each year for the next five years, continued expansion of IAPT services and the funding of Mental Health Support Teams laid out in the NHS Long Term Plan are all welcome plans.

However the NHS Long Term plan contained just two references to LGBT people, if significant steps are to be made in eliminating health inequalities faced by LGBT people, including disproportionately poorer mental health among GBT men, government plans and policy need to specifically mention LGBT people and outline specific steps in addressing LGBT health inequalities. While LGBT specific policy documents, such the LGBT Action Plan 2018 are welcomed, LGBT people need to be specifically mentioned throughout wider policy documents and plans, such as the NHS Long Term Plan. 

5.2 LGBT Action Plan

The government needs to ensure it acts on promised improvements to mental healthcare for LGBT people that are laid out in the LGBT Action Plan 2018. We welcome plans to work towards reducing suicides among the LGBT population, including addressing LGBT people’s needs in the updated Suicide Prevention Strategy. However action to improve mental health for LGBT people needs to go further.

For example steps must be taken to reducing stigma surrounding accessing metal health support specifically for GBT men, something that isn’t mentioned in the Action Plan. This is vital considering 22.8% of GBT men said they were worried, anxious or embarrassed accessing services.

The National Advisor

We welcome the plan to appoint a National Advisor to lead improvements to LGBT healthcare. This Advisor must ensure that improving mental health of LGBT people is a high priority. They must work collaboratively with other organisations, including VCS organisations and have access to up-to-date research in order to ensure that they have a comprehensive understanding of the key mental health issues faced by LGBT people and are aware of work being done to reduce these issues. They must be aware of the complex range of factors that affect the mental health of GBT men and boys (as outlined in Section 2).

5.3 LGBT Inclusive Relationship and Sex Education

We welcome plans to plans to introduce widespread LGBT inclusive RSE in schools and believe that this will go some way improving the experiences of LGBT pupils. We urge the government to fully commit to these plans and not be influenced by opposition.

In schools where pupils are taught about LGBT issues pupils are less likely to experience homophobic, biphobic and transphobic bullying (43% compared to 49%).[35]

6. Sexual Orientation and Trans Status Monitoring

Current understandings on the mental health of GBT men and boys and the contributing factors to poorer mental health are still limited. A vital way in which the evidence base can be expanded is by implementing sexual orientation monitoring (SOM) and trans status monitoring (TSM) across the health and social care sector.

The NHS Long Term Plan has made commitments to better understand at risk groups and highlight inequalities in order to improve person centred care. Widespread implementation of SOM and TSM is a vital step in increasing understanding of the LGBT population and making evidence based steps to improving person centred care for LGBT people.

It is important to note that sexual orientation and trans status are different and should be asked as separate questions on demographic monitoring forms.

• Sexual orientation monitoring guidance- LGBT Foundation has helped to develop the NHS England Information Standard which offers advice and practical tips for organisations on how to best monitor sexual orientation. This guide can be found here: https://lgbt.foundation/resources-and-information/policy/guidance/monitoring/guide

• Trans status monitoring guidance - LGBT Foundation have produced a briefing sheet on implementing TSM this guide can be found here: https://s3-eu-west-1.amazonaws.com/lgbt-media/Files/733001ca-5a3f-40de-81ac-bcac5cf88c2e/TSM%2520Briefing%2520Sheet.pdf

March 2019