Written submission from Stonewall (MHM0010)

Introduction

1. Stonewall welcomes this inquiry, which offers a vital opportunity to raise awareness of the mental health challenges faced by men and boys. Gay, bi and trans (GBT) men and boys experience particularly high rates of poor mental health; this response will focus on the prevalence of poor mental health among this group, the factors driving these inequalities, and how they can be addressed.
2. Stonewall is Britain’s largest organisation campaigning for lesbian, gay, bi and trans (LGBT) equality. Through our Diversity Champions programme we work with over 80 health and social care organisations, including NHS England and Public Health England, to help them create LGBT-inclusive workplaces and deliver LGBT-inclusive services. Alongside this, we work with hundreds of primary and secondary schools and over 50 local authorities through our School Champions and Education Champions programmes respectively to equip them to effectively support LGBT young people. We have commissioned high-quality independent research into LGBT people’s mental health and have produced extensive guidance and resources for public services and schools on LGBT inclusion.

Prevalence of poor mental health among GBT men and boys

3. GBT men and boys experience particularly high rates of poor mental health, with trans men and GBT boys at greatest risk.
4. School Report (2017), Stonewall research with the University of Cambridge into the experiences of over 3,700 LGBT young people aged 11-19 in Britain, found that:

• Half of GBT boys (51 per cent) have deliberately harmed themselves
• This compares to NHS estimates that roughly one in ten young people in general have deliberately harmed themselves
• Seven in ten GBT boys (71 per cent) have thought about taking their own life
• In comparison, Young Minds estimates that one in four young people in general have had these thoughts
• One in four GBT boys (24 per cent) have attempted to take their own life at some point
• By contrast, the NHS estimates that five per cent of boys aged 16-24 have tried to take their own life
• Trans young people experience particularly high rates of poor mental health: nearly half (45 per cent) have tried to take their own life at some point, while more than four in five (85 per cent) have self-harmed

5. These findings were mirrored by NHS Digital’s new data on children and young people’s mental health (the first national data since 2004), which found that lesbian, gay and bi young people were significantly more likely to suffer from a mental health disorder than heterosexual young people:

• One third of lesbian, gay and bi 14-19 year olds (35 per cent) have a mental disorder; this compares to one in eight heterosexual 14-19 year olds (13 per cent)

6. LGBT in Britain: Health Report (2018), Stonewall research with YouGov into the experiences of over 5,000 LGBT adults in Britain, found that:

• Nearly half of GBT men (46 per cent) said they’ve experienced depression in the last year and more than half (54 per cent) said they’ve experienced anxiety in the same period
• According to Mind, roughly one in six adults in general in England report experiencing a common mental health problem (such as anxiety and depression) in any given week
• One in eight LGBT people aged 18-24 (13 per cent), 12 per cent of trans people and two per cent of cis LGB adults have tried to take their won life in the past year
• Three in five trans people (60 per cent), 43 per cent of bi men and 32 per cent of gay men said they felt at some point over the last year that life was not worth living
• According to NHS Digital, one in twenty adults in general reported thoughts of taking their own life in the past year, and fewer than one per cent said they attempted to take their own life in the past year

Factors driving high rates of poor mental health among GBT boys and men

7. GBT boys and men face numerous specific challenges relating to their sexual orientation/gender identity from a young age and into adult life which can have a profound impact on their wellbeing.

Homophobic, biphobic and transphobic bullying and language at school

8. At school, while significant progress has been made, homophobic, biphobic and transphobic bullying and language remains commonplace:

• School Report 2017 found that nearly three in five GBT boys (57 per cent) are bullied at secondary school for being LGBT. Trans young people experience significantly higher rates of bullying than LGBT young people in general (64 per cent compared to 45 per cent)
• The Teachers’ Report (2014), Stonewall research with YouGov into the experiences of over 1,800 primary and secondary school staff in Britain, found that nearly half of primary teachers (45 per cent) say pupils in their schools have experienced homophobic bullying

‘I have been bullied since Year 2 for being gay. People called me names like ‘gay’ and ‘faggot’ before I even knew what they really meant.’

Kieran, 18, private sixth form college (East of England)

9. This bullying can have a significant impact on GBT boys’ wellbeing. LGBT pupils who have been bullied for being LGBT experience particularly high rates of poor mental health: School Report 2017 found that LGBT young people who have been bullied for being LGBT are significantly more likely to have attempted to take their own life than those who haven’t (37 per cent compared to 17 per cent).

Impact of gender stereotypes from a young age

10. Gender stereotypes can have a profoundly constricting impact on all young people, including GBT boys. Gender stereotypes underpin much anti-LGBT prejudice and abuse: for example, a boy who does not conform to the stereotypical role or characteristics of ‘what a boy is’ may face ridicule or abuse for being GBT, irrespective of whether they are or not. The Teachers’ Report (2014) found that homophobic bullying is closely linked to gender stereotypes: among primary teachers who are aware of homophobic bullying in their schools, half (49 per cent) say boys ‘who behave or act like girls’ are bullied, while in secondary schools, this figure is 45 per cent for ‘boys who behave or act like girls’ and 22 per cent for ‘boys who don’t like or play sports’.

‘At my previous school a lot of boys were very traditionally masculine so I didn’t fit in with many of them in terms of hobbies, likes and interests. This was a cause of tension between me and some of the other guys as they didn’t like that I wasn’t ‘manly’, which caused isolation in PE lessons as well as verbal bullying.’

Callum, 15, special school (West Midlands), School Report 2017

11. Gender stereotypes are also closely linked to stereotypes about LGBT people: for example, the stereotype that gay men are ‘effeminate’ is both used to mock gay men who do not conform to stereotypes of ‘what a man is’, and to imply that all gay men are the same, obscuring the diversity that exists in the community. Gender stereotypes can therefore negatively shape how GBT boys and men see themselves (and their self-esteem, wellbeing and mental health) as they are growing up and into later life.

Gaps in support at school and home

12. While significant progress has been made, many schools are still not equipped to support LGBT young people.
13. School Report 2017 found that more than half of LGBT pupils (53 per cent) say there isn’t an adult at school they can talk to about being LGBT. Schools teaching LGBT-inclusive RSE continue to be in the minority, leaving many GBT boys with no choice but to go online to find information about having healthy relationships and practicing safe sex; this information is often unreliable, and so LGBT young people are more likely to engage in risky behaviour and be at risk of sexual exploitation, all of which can have an impact on their wellbeing.

• Just one in five LGBT pupils (20 per cent) have learnt about where to go for help and advice about same-sex relationships at school, while thirteen per cent have learnt about how to have healthy relationships in relation to same-sex relationships
• Three in four LGBT pupils have never learnt about bisexuality (76 per cent) and gender identity and what ‘trans’ means (77 per cent), leaving many young people without the information they need to positively understand and explore their identity at a timely point

14. Many trans young people continue to be unable to access the support they need at school. School Report 2017 found that:

• More than two in five trans pupils (44 per cent) say that staff at their school are not familiar with the term ‘trans’ and what it means
• A third of trans pupils (33 per cent) are not able to be known by their preferred name at school

‘No one I’ve spoken to at school has ever knowingly met a trans person before or been taught anything about trans people and what we might need.’

Reece, 18, now in employment (Yorkshire and the Humber)

15. The support of family and friends can be vital in supporting a person’s health and wellbeing. However, many GBT boys and men continue to face a lack of support at home. Among LGBT young people, just two in five (40 per cent) have someone at home they can talk to about being LGBT (School Report 2017). Among LGBT adults, LGBT in Britain: Home and Communities, Stonewall and YouGov research into the experiences of over 5,000 LGBT people, found that more than half of lesbian, gay and bi people (54 per cent) don’t feel able to be open about their sexual orientation or gender identity to everyone in their family. Three in ten bi men (30 per cent) say they cannot be open about their sexual orientation with any of their friends.

Experiences of violence and prejudice

16. LGBT people – including GBT men – continue to experience high rates of hate crimes and incidents in Britain today. LGBT in Britain: Hate Crime and Communities (2017), Stonewall and YouGov research into the experiences of over 5,000 LGBT adults in Britain, found that:

• One in five LGBT people (21 per cent) – including two in five trans people (41 per cent) – have experienced a hate crime or incident due to their sexual orientation and/or gender identity in the last 12 months.
• Most LGBT people who experience a hate crime or incident did not report this to anyone (including the police or support organisations), many because they were not confident that their report would be taken seriously: four in five LGBT people (81 per cent) who experienced a hate crime or incident in the last 12 months did not report it to police.

17. These experiences can have a profound impact on GBT men’s mental health: LGBT in Britain: Health Report (2018) found that rates of both depression and anxiety are particularly high among LGBT people who have experienced an anti-LGBT hate crime in the last year (69 per cent and 76 per cent respectively).
18. GBT men also face particularly high rates of intimate partner violence, which can have a profound impact on their wellbeing: LGBT in Britain: Home and Communities (2018) found that 21 per cent of trans men, 12 per cent of bi men and seven per cent of gay men have experienced domestic abuse from a partner in the last year. According to the ONS, three per cent of men in general have experienced domestic abuse from a partner in the last year.

Alcohol

19. LGBT in Britain: Health Report (2018) found that GBT men are more likely to drink alcohol regularly than adults in general. In the last year, one in five GBT men (20 per cent) drank alcohol almost every day; according to the ONS, one in ten adults in general (10 per cent) drink alcohol on five or more days in the week.

Access to health and social care support

Poor access to mental health support

20. Mental health services are currently under significant strain, resulting in lengthy waiting times for many GBT men – alongside the general population overall – who need support.
21. The Government’s National LGBT Survey (2018), which had over 108,000 LGBT respondents, found that 16 per cent of GBT men – including two in five trans men (40 per cent) – had accessed mental health services in the last 12 months, while five per cent had tried to access them but had been unsuccessful. Nearly three quarters (72 per cent) of those who had accessed or tried to access mental health services reported that it had not been easy, with 51 per cent saying that the wait had been too long, while 27 per cent had been worried, anxious or embarrassed about going.

Discrimination in health and social care services

22. Despite a clear need, many mental health services – alongside wider health and social care services – are not equipped to fully meet the needs of GBT men.
23. LGBT in Britain: Health Report (2018) finds that while progress has been made, many LGBT people – particularly those who are trans – continue to experience discriminatory treatment in health and social care services. This can take the form of being ‘outed’ without their consent, treated with inappropriate curiosity or subjected to unequal treatment because of who they are. This treatment – both experienced and expected – can deter many LGBT people from seeking support when in need:

• Eleven per cent of bi men, nine per cent of gay men and a third of trans people (32 per cent) have experienced unequal treatment from healthcare staff because they’re LGBT
• Nearly one in four LGBT people (23 per cent) have at one time witnessed discriminatory or negative remarks against LGBT people by healthcare staff
• Two in five bi men (40 per cent), 10 per cent of gay men and nearly one in five trans people (18 per cent) aren’t out to anyone about their gender identity when seeking medical treatment
• One in seven LGBT people (14 per cent) – including more than a third of trans people (37 per cent) – have avoided treatment for fear of prejudice

24. Mirroring the findings of the National LGBT Survey, LGBT in Britain: Health Report (2018) found that one in twenty LGBT people (five per cent) have been pressured to change their sexual orientation when accessing healthcare services, while one in five trans people (20 per cent) have been pressured to access services to suppress their gender identity when accessing healthcare services. These services can have a profound and enduring impact on LGBT people’s self-esteem, wellbeing and mental health.
25. Alongside ensuring that mainstream mental health services are equipped to meet the needs of LGBT service users through clear policies and training, LGBT-specific services can be vital in meeting the needs of local LGBT communities: for example, MindOut is an LGBT-led project, funded by Brighton and Hove City Council and Brighton and Hove CCG among other organisations, which provides peer support groups and online and in person counselling for LGBT people. Connect counselling, run by Terrence Higgins Trust, is a specialist low-cost counselling service for gay and bi men in London, which provides individual and group counselling and psychotherapy.

Transition-related healthcare

26. In their 2016 Transgender Equality Inquiry, the Women and Equalities Select Committee (WESC) received ‘significant evidence of the toll taken (in poor mental health, self-harming and suicide attempts) by untreated gender dysphoria’. A 2012 Scottish Trans Alliance study found that lengthy waiting times for initial Gender Identity Clinic (GIC) consultations had an adverse impact on mental health, with 58 per cent of participants feeling that this wait had led to their mental health or emotional wellbeing worsening in this time. Conversely, those who wanted, and were able, to medically transition reported substantial improvements in their mental health.

27. The 2016 Women and Equalities Select Committee’s (WESC) Transgender Equality Inquiry stated that ‘the NHS is letting down trans people, with too much evidence of an approach that can be said to be discriminatory and in breach of the Equality Act’. This is having a significant impact on trans men’s mental health.

28. There is growing demand for Gender Identity Development Services (GIDS) for young people. While GPs can refer young people to GIDS, referral chiefly takes place through CAMHS. The 2016 WESC Inquiry stated that many CAMHS staff have not been equipped with training on gender identity, and incidences of discriminatory treatment and lack of awareness of referral pathways are commonplace. Most of those seeking access to GIDS must endure lengthy waiting times and travel to London (Vision for Change, Stonewall Trans Advisory Group 2018). In addition, trans respondents to the WESC Inquiry stated that transition from GIDS to adult gender identity services is frequently difficult, with many young people experiencing a hiatus in care after entering a GIC waiting list. 

Recommendations

The Department of Health and Social Care:

• The implementation of the Transforming Children and Young People’s Mental Health Provision Strategy should be recalibrated in light of NHS Digital’s recently published statistics on young people’s mental health, and should be significantly upscaled and accelerated to help more young people benefit from the proposals
• The needs of GBT men, alongside LGBT people in general, should be explicitly addressed in the updated Suicide Prevention Strategy
• The curriculum for the new Mental Health Support Teams should include guidance on meeting the needs of all LGBT young people, including specific guidance on supporting trans young people
• The training provided for all Designated Senior Leads for mental health in schools and colleges should include guidance on meeting the needs of LGBT young people, including specific guidance on supporting trans young people

The Department for Education:

• To ensure that all young people grow up with accepting and understanding attitudes towards themselves and each other, the final guidance on teaching Relationships Education at primary level should make it clear that all schools should include LGBT families in teaching on ‘different families’. The overall guidance must be updated to ensure that schools understand that all their teaching at primary and secondary level should be LGBT-inclusive.
• Stonewall welcomes the introduction of compulsory Health Education, alongside compulsory Relationships and Sex Education. To ensure that teachers are equipped to meet the needs of all young people in this teaching, sufficient investment must be provided to ensure all teachers delivering these subjects can access basic, LGBT-inclusive training, alongside high-quality LGBT-inclusive resources.

NHS England:

• The new National LGBT Health Adviser should make mental health, including the mental health of GBT boys and men, a key priority
• NHS England should also support the routine implementation of the Sexual Orientation Monitoring Information Standard in mental health services by providing training and guidance for practitioners
• As part of their 2019 review of adult gender identity services, it is vital that NHS England set out a clear plan to increase capacity and reduce waiting times to gender identity services, particularly regarding their plans to recruit more practitioners to become gender identity specialists, and explore and implement new models of care to address gaps in provision, for example the introduction of ‘enhanced’ roles for GPs with a special interest in trans healthcare.

NHS Digital:

• All future studies on the national prevalence of poor mental health among young people and adults among young people adults should include analysis in respect of both sexual orientation and gender identity, including for people with multiple protected characteristics (such as BAME LGBT people and LGBT disabled people) to identify inequalities and develop targeted interventions

Medical and nursing schools, the Royal College of Psychiatrists, the British Psychological Society and mental health training providers:

• Curricula, standards and compulsory and ongoing training should be reviewed to ensure they are fully inclusive of the mental health needs of LGBT people

NHS mental health services:

• All staff should be trained on the mental health needs of LGBT people (including specific training for CAMHS practitioners on referral pathways for GIDS)
• Services should consistently monitor patients’ sexual orientation (using the Sexual Orientation Information Standard) and gender identity, supported by training for practitioners, to identify inequalities in LGBT patient experience and outcome and develop targeted services and initiatives to address these (such as specific counselling groups for GBT men)
• LGBT-inclusive information and resources should be made readily available for patients and service users

Schools:

• All schools should have:
• Clear and widely promoted policies and procedures on tacking homophobic, biphobic and transphobic bullying and language
• Training for staff on tackling homophobic, biphobic and transphobic bullying and language and delivering LGBT-inclusive teaching
• Specific training for pastoral staff on supporting the specific health and wellbeing needs of LGBT young people, alongside making it clear to all pupils that they can talk to pastoral staff about issues relating to their sexual orientation and gender identity

February 2019