February is UK Lesbian, Gay, Bisexual and Trans History month and in 2024 the theme is medicine, discussing the contributions of LGBT+ people to medicine, highlighting the difficult history of the pathologisation of sexual identity and the health inequalities that still affect LGBT+ communities.
Public Health has an interesting past when it comes to LGBT+ inclusion, in general we have been relatively silent on the inequalities affecting these communities outside of HIV, which I think is to our detriment. The evidence of significant mental health inequalities could be argued to be as strong as that for HIV and STI, yet we rarely see inclusive approaches to public mental health policy and for decades the only recognition of this inequality in policy was a single sentence in the women’s mental health strategy.
It still remains rare for JSNAs to comment on LGBT+ inequalities despite the significant body of evidence of health inequalities. Across the country there have been scattering of LGBT+ specific needs assessments but these are few and far between. This is despite some good work over the years to help pull together the evidence base linked to Public Health outcomes including some key documents from Public Health England:
The Lesbian, Gay, Bisexual & Trans Public Health Outcomes Framework Companion Document (2013)
The Adult Social Care Outcomes Framework Lesbian, Gay, Bisexual and Trans Companion Document (2013)
Promoting the health and wellbeing of gay and bisexual and other men who have sex with men (2016)
These kind of documents are so important in helping us better understand the needs of LGBT+ people. As we improve the inclusion of sexual orientation and gender identity questions into routine and population level data sets we increase our understanding of the inequalities affecting these communities.
Often we tend to homogenise inequalities down to poverty, and it is important to flag that there is international evidence[i] [ii] that demonstrates that poverty is more common in LGBT+ communities than in their cis-gender and heterosexual counterparts, so when we are looking at socio-economic inequality we should be looking at LGBT+ communities as a specific disadvantaged community.
In Birmingham we have built on these further to develop specific community health profiles to help us better understand some of the differences between the L, G, B and T communities as well as their inequalities compared to cis-gender and heterosexual communities. These profiles are desktop needs assessments that are followed by a year of co-embedding with local communities to co-develop sustainable interventions with community members to address the findings. Our JSNA and our deep dive needs assessments include discussion of LGBT+ inequalities, alongside discussion of ethnic and disability disparities, even if it is only to say local data is not available but national or international research shows inequality.
So what does this mean for our approach to training and CPD as public health professionals?
In the Faculty of Public Health’s Public Health Specialty Training Curriculum there is no specific requirement to understand LGBT+ inequalities, the context of diversity and inclusion is limited in the 2022 Curriculum as a cross-cutting theme which only explicitly mentions racism and falls short of the breadth of legally protected characteristics.
This is something the Faculty should consider in future iterations as the curriculum forms the basis of our pre-CCT focus and is key to how we embed the skills and knowledge for the growing diversity of the populations we serve. We have a duty to consider the legally protected characteristics and not create hierarchies of equality in our application of the curriculum and in our training.
However there is plenty of potential in terms of how we demonstrate competency through training and our CPD reflective practice. Specifically if as educational supervisors and ARCP panels we are explicit in our expectation that through training individuals demonstrate cultural competency across the minimum of the nine legally protected characteristics in line with Competency 9.8.
Competency 9.8 ‘Demonstrate cultural competence and is able to work effectively in cross- cultural situations both internally and externally to the organisation.’
Birmingham is currently developing a Cultural Intelligence Framework to support individuals to develop competencies in understanding of different communities. This builds on our work jointly with Lewisham on inequalities affecting African and Caribbean communities and the recognition that public health, and health in general, over homogenised communities and under-valued the differences between them This framework should be launched later this year as an evaluated pilot, but in the interim there is a lot of information, webinars and training available to help deeper understanding of different communities within the LGBT+ and the intersectionality within them.
We have a duty as public health professionals to address health inequalities and it is not acceptable for us to have a hierarchy of equality as this simply increase inequalities in those communities that are ignored. We cannot close the gap unless we go beyond the homogenised over-simplified socio-economic inequality short-hand and to do this we need to get much more granular in understand the diversity of the communities we serve.
So this LGBT+ history month take some time to update your own competency in understanding LGBT Health Inequalities!
Dr Justin Varney
Director of Public Health, Birmingham City Council
REFERENCES
[i] https://williamsinstitute.law.ucla.edu/publications/lgbt-poverty-us/
[ii] https://www.hrc.org/resources/understanding-poverty-in-the-lgbtq-community
Leave a comment