Social Determinants of LGBTQ+ Health
In the UK, transgender people engage with health services at a lower rate than the non transgender population. This includes lower levels of engagement with important health screening services such as breast, cervical and prostate cancer screening programs.
Why does this matter? In global terms LGBT people have significantly poorer determinants of health than the general population, and new research is revealing that the consequences of anti LGBT discrimination, including in relation to healthcare access, has a significant economic impact globally. Anti-LGBT discrimination is estimated to cost countries where it is an accepted cultural norm, in the region of 1% of their gdp annually. 
Discrimination has meant that until recently, even in supposedly advanced economies, this has been a poorly researched area. To illustrate, an academic literature search using four search terms “Gay and Lesbian Health,” “Transgender Health,” “LGBT Health,” and “Transsexual Health” produced 434 results between 1980 and 2010, compared to 4,048 results between 2011 and 2021.
In the health and social care field the term “social determinants of health” refers to the socio-economic conditions into which a person is born, lives and dies. Public Health England describe them as “…avoidable and unfair differences in health status between groups of people or communities” [2, 3]
The evidence around social determinants of LGBT people’s health globally describes a situation where discrimination is widespread and deep rooted and LGBTQ+ people face significant forms of disadvantage, which varies by location. In 2018, same sex relationships were criminalized in 76 countries, including being punishable by death in eight places. [4, 5]
The far reaching consequences of this globally on LGBT people’s lives, education achievement, economic opportunities and life long income potential is only now beginning to be described.
The term Allostatic Load refers to the cumulative burden of chronic stress and harm a person experiences. LGBT people, like people in many minority groups, face increased risk of long term health problems due to the increased allostatic load created by discrimination and social exclusion.
Higher stress levels among people in poorer and minority communities are also linked with riskier health behaviours, for example smoking, the consumption of alcohol and recreational drugs which often compounds the risks of harmful health consequences. 
As well as the socio-economic determinants of health, it is known that Adverse Childhood Experiences (ACEs) such as bullying, abuse, neglect or bereavement for example, have significant increased risk of adverse consequences for an individual’s long term wellness and health outcomes. These occur at significantly higher rates for LGBT people, compared to non-LGBT people in equivalent circumstances.
In Europe a study from the Netherlands found that 56% of transgender people reported experiencing 4 or more traumatic childhood events. It’s known from other research that experiencing 4 or more such events correlates with a significantly increased risk of engaging in health harming behaviours, such as smoking, alcohol and drug abuse. With numerous associated risks like heart disease, increased incidence of cancers, hypertension, diabetes and other conditions often described as “lifestyle” illnesses. 
This type of stress has been measured in physiological responses too, as elevated markers of inflammation. Described as the cumulative advantage —-or disadvantage, hypothesis. 
The cost to people’s mental health is significant. In 2017, 52% of UK based LGBT people reported they experienced depression during the previous year. Including 67% of transgender people. 
Even in the UK, where LGBT rights are considered to be quite advanced, transgender people still face serious forms of discrimination. 41% of transgender people report experiencing hate-crime related to their gender identity. 
The unemployment rate in the UK for transgender people is significantly higher than the the rate for non transgender people. According to the UK government’s equality office only 65% of transgender women and 57% of transgender men had paid employment in the 2018 survey period. 
Discrimination against people for being LGBT is lifelong and often begins in childhood. In the UK 45% of LGBQ school students, and 64% of transgender school students have experienced bullying over being LGBT. The government's 2018 report “Is Britain Fairer” found that 50% of transgender University students had considered dropping out of their courses and 30% of transgender University students had experienced some form of bullying during their studies. Transgender people in the UK are highlighted in the report as a group who experience particularly poor socioeconomic outcomes with respect to the general population. This report also found that 20% of LGB people and 40% of transgender people reported being subject to hate crimes during the reporting period in 2018-2019.  Despite legal protections, workplace bullying is still commonplace with 48% of transgender employees reporting some form of bullying vs a reporting level of 35% of non trans people. 
Compared with other developed economies, the transgender community in the UK has been very poorly served in regards to healthcare, not just when it comes to accessing gender identity services. For example in many important health metrics transgender people are excluded by omission or entirely overlooked. In the USA, data on cancer screening includes information relating to gender identity, enabling research to be carried out. [19, 20]
I emailed the team in charge of The equivalent NHS cancer tracking database, established in 2013, to ask for similar information regarding UK transgender people, they explained their data isn’t granular enough to tell us anything about transgender people’s outcomes. 
Physical Health, Knowledge Gaps and Increased Risk.
There are many gaps in transgender people's and LGBT health care generally, examples which illustrate the larger issue in terms of physical health include ongoing risks associated with a person’s sex assigned at birth, such as ovarian, breast and prostate cancers. Another is the health impact of long term testosterone supplementation and estrogen supplementation. Trans people often require these hormones at greater dosages which differ from those generally prescribed to non transgender people.
Despite these health care needs, transgender people’s engagement with health screening services is proportionally lower than among the non transgender population. According to Stonewall’s “LGBT in Britain Health Report 2018” 37% of trans people and 33% of non-binary individuals report avoiding healthcare services out of fear of discrimination. 62% of transgender people report experiencing a lack of knowledge or understanding on the part of healthcare professionals in the same report. 48% of transgender respondents also reported inappropriate questioning or discussion at the hands of healthcare professionals. Lack of practitioner knowledge about transgender people is also recognized by the Royal College of Nursing as an issue affecting healthcare access. 
It’s believed that transgender men have a two fold higher rate of cancer diagnoses than non-transgender men. Some transgender men retain their cervix, and this combined with testosterone supplementation creates a situation where regular screening is necessary but is rarely well implemented or engaged with. One review of literature from 2018 on the incidence of breast cancer among transgender men found that while the rate remains low the data is contradictory. Not all breast tissue is removed during mastectomy surgery and a slightly elevated yet poorly defined risk remains. The same paper noted that transgender men also present for breast screening less often than cisgender women. Also stated was the fact that at the time of writing there was no reliable data for the incidence of breast cancer in transgender women. 
Similarly transgender women retain their prostate gland. When I emailed UK prostate screening services I was told there is currently no research being conducted in the UK on the relative cancer risks transgender women may face. It’s thought to be lower because hormone interventions for gender identity reduce the risk. However its known that genetic predisposition means even this may not help some people. We don’t know which ones because while some screening services are offered as a matter of course to transgender people based on their gender change, Public Health England’s website leaves it in the hands of individual transgender people to book appointments with breast, cervical and prostate screening services themselves. 
As transgender people are a group who avoid interacting with healthcare services, for good reasons, providing only passive general healthcare advice via a government website illustrates the lack of a coherent strategy.
Healthcare professionals can work to ensure clinic spaces are explicitly inclusive of transgender people, particularly where the health care being delivered has a gendered component. This was suggested by nurses who participated in a study in Canada, where it was also found that there were no specific policies with regard to the inclusion of transgender patients. [26, 27] Developing clinic specific policies towards towards transgender patients also presents a unique opportunity for staff training.
Care for transgender people should be viewed as an issue of cultural competence, which it currently often isn’t. With transgender patients viewed through outdated ideas, as rarities devoid of socio-cultural context, or viewed only through a mental health lens. Historically, people in LGBT communities globally have by necessity been forced to take a lead in creating their own unofficial healthcare pathways. Through community advice and mutual aid LGBT people have accessed drug treatments and established mental health counselling services and information hubs. Transgender people in the UK have created support services related to cervical screening , and access to important hormone treatments. However, relying on improvised community approaches to healthcare has very important and obvious limitations, among them being their stratified nature. It tends to be people who already have the best resources who can access them most easily. Plus their atomized nature means ad-hoc services are not always reliable.
The TL/DR Summary
LGBT people, and transgender people in particular, are significantly affected by negative health determinants. This creates poorer levels of engagement with important healthcare services than would be expected. It has also been shown that there are still significant knowledge gaps and basic questions about the health and life expectancy of trans people which have yet to be understood and clearly defined. The evidence shows that as well as causing harm to the individual, there is a sizable economic cost for societies which tolerate anti-LGBT sentiment. Despite this there are growing opportunities for positive engagement and the creation of more inclusive services. With healthcare professionals playing a leading role as part of a movement towards better treatment of, and rights for, transgender, lesbian, gay and bisexual people globally.
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