LGBT Health Survey Merseyside - Results and Response by MacmillanLGBTCancerProgrammeMerseyside

LGBT Health Survey Merseyside Results and response

Autumn 2018

In partnership with

Contents Executive Summary ............................................................................................................................................. 3 Acknowledgments ................................................................................................................................................ 5 LGBT people and health inequalities ................................................................................................................ 6 LGBT Cancer Programme Merseyside ............................................................................................................. 9 Methodology ........................................................................................................................................................10 The Survey ......................................................................................................................................................10 Data Processing and Analysis ......................................................................................................................11 Demographics of respondents .........................................................................................................................12 Gender .............................................................................................................................................................12 Gender Identity ...............................................................................................................................................13 Sexuality ..........................................................................................................................................................14 Ethnicity............................................................................................................................................................15 Age....................................................................................................................................................................16 Borough............................................................................................................................................................17 General Health ....................................................................................................................................................18 Physical Health ...............................................................................................................................................18 Physical Activity ..............................................................................................................................................20 Mental Health ..................................................................................................................................................22 Being LGBT in healthcare settings ..................................................................................................................24 Disclosure of sexuality ...................................................................................................................................24 Disclosure of gender identity ........................................................................................................................28 Discrimination..................................................................................................................................................30 Experiences of discrimination .......................................................................................................................31 Withholding information .................................................................................................................................33 Experiences of withholding information ......................................................................................................34 Resources targeted to LGBT people ...........................................................................................................36 Your experiences of cancer ..............................................................................................................................43 Screening .........................................................................................................................................................43 Knowledge of cancer .....................................................................................................................................47 LGBT people and smoking ...............................................................................................................................48 Prevalence of smoking ..................................................................................................................................48 Frequency of smoking ...................................................................................................................................49 Smoking and the LGBT community .............................................................................................................50

LGBT people and alcohol ..................................................................................................................................52 Prevalence of drinking ...................................................................................................................................52 Frequency of drinking ....................................................................................................................................53 Alcohol and the LGBT community ...............................................................................................................54 LGBT people and drugs ....................................................................................................................................57 Prevalence of drug use..................................................................................................................................57 Types of drugs used.......................................................................................................................................58 LGBT people and tanning .................................................................................................................................59 Prevalence of self-tanning.............................................................................................................................59 Self-tanning and the LGBT community .......................................................................................................60 Comments on the survey ..................................................................................................................................62 Interpreting the data and making recommendations ....................................................................................67 Campaigns ......................................................................................................................................................67 Research..........................................................................................................................................................68 Training and Resources ................................................................................................................................69 References............................................................................................................................................................71 Appendix A – Blank Questionnaire ......................................................................................................................73 Appendix B – Full Answers to Q16 ......................................................................................................................88 Appendix C – Full Answers to Q18 ......................................................................................................................91 Appendix D – Full Answers to Q32 ......................................................................................................................93 Appendix E – Full Answers to Q36 ......................................................................................................................96 Appendix F – Full Answers to Q41 ......................................................................................................................99 Appendix G – Full Answers to Q42 ................................................................................................................... 101

Executive Summary There is an ever-growing body of research nationally which highlights that LGBT people face significant inequalities when it comes to health. Whilst further research is needed to be able to identify the cause of this, our anecdotal knowledge of LGBT communities allows us to develop ideas as to why this is. Regional research is also incredibly important as it allows us to go beyond a national picture to identify and address nuances and inequalities in specific areas. Across the country - in places like Brighton, London and Manchester important research is being undertaken on the health and wellbeing of LGBT people. It is our hope that this survey will form part of a growing body of research and work into the health of LGBT people in Merseyside. Since launching the survey, the responses and feedback we have received have far surpassed our expectations. LGBT people across Merseyside have been keen to have their voice heard, and have frequently articulated their support for our work. This shows us that not only is our work wanted, but it is necessary and urgent. This research was conducted as part of the LGBT Cancer Programme, a Macmillan initiative in partnership with Sahir House. The programme has been established to improve the outcomes of LGBT people living with and affected by cancer in the region. The results of this survey are hugely important to us, and provide a baseline from which to begin our work with LGBT people, as well as identifying important health inequalities. As this research forms part of a programme around cancer, much of this report and its recommendations are centred around cancer. However, we are also keen for the survey to be a useful resource for further research into the health and wellbeing of LGBT communities in Merseyside more broadly. The survey asked questions around a number of areas relating to health and wellbeing. We asked about their current physical and mental health and how often they undertook physical exercise. We asked about our respondents experiences in healthcare settings: if they were out to medical or sexual health professionals, and if not why not; if they had ever withheld information from 3

medical professionals through fear of a negative reaction to their sexual orientation or gender identity; if they had ever witnessed or experienced discrimination and if they had ever seen resources aimed at LGBT communities. We also asked about their knowledge of cancer, their uptake of cancer screenings as well as their relationship with cancer causing behaviours. Some of the findings from this survey have made for difficult reading, including: o Nearly 3 in 4 LGBT people in Merseyside have experienced some form of mental health issue in the last two years. This rises to over 9 in 10 amongst Trans people o 1 in 3 LGBT people in Merseyside have encountered discrimination in a medical setting. This rises to 4 in 10 amongst Lesbian and Bisexual women o 1 in 4 LGBT people in Merseyside do not disclose their sexuality to a medical or sexual health professional, with nearly 1 in 3 stating that they had purposefully withheld information from medical professionals through fear of a negative reaction o Over 1 in 4 LGBT people in Merseyside identify as smokers, higher than the national population average and the national average amongst LGBT people o Nearly 1 in 5 LGBT people in Merseyside use recreational drugs as part of their social or home life. This rises to nearly 1 in 4 amongst Male respondents. This report concludes with a series of recommendations based upon findings drawn from our survey data for areas of improvement. The implementation of the recommendations in these areas will work to better the outcomes of LGBT people in Merseyside living with or affected by cancer.

Acknowledgments We would like to thank the countless individuals and organisations that supported our work and helped circulate the survey ensuring it reached as many people as possible. We would also like to thank anyone who provided input, assistance or advice as the survey was being compiled and as this report was being written. We would further like to thank anyone who had previously conducted research into LGBT people and cancer, without whom this survey would not have been possible, as well as the teams at Macmillan and Sahir House. Finally, we would like to thank everyone who gave their time and shared their experiences with us, however challenging this may have been. We will endeavour to translate their openness and honesty into improvements that benefit LGBT people across the region.

LGBT people and health inequalities This survey was designed to join a growing body of research into health inequalities for LGBT communities, with a focus on specific geographic regions. We know that LGBT people face significant health inequalities. The recently published the National LGBT Survey, commissioned by the Government Equalities Office, provides the most comprehensive national picture to date on the lives and experiences of LGBT people in many areas including health. Over 108,000 LGBT people participated, making it the largest survey of LGBT people in the world to date.1 Amongst other findings, the report concluded that LGBT people are more dissatisfied with health services than the wider population.2 It also showed a higher prevalence of mental health issues amongst LGBT people than the wider population, with 24% having accessed mental health services in the previous year.3 This figure is even higher amongst trans people, at 30% for trans women and 40% for trans men.4 The report also highlighted concerns about the suitability of sexual health and gender identity services.5 We also know that LGBT people face health inequalities when it comes to cancer. The Department of Health, as part of the Cancer Patient Experience Survey (CPES), commissioned a four year study which provided the first baseline data on the experiences of LGB patients with cancer and highlighted that they were less likely to say that their experience was positive than heterosexuals.6 Differences included in accessible information, psychosocial support and treatment with dignity and respect, also pain management.7 It also showed that LGB people were more likely to disagree with such statements as

Government Equalities Office, National LGBT Survey: Research Report (London: HM Government, 2018). p.6. Ibid., p.161. 3 Ibid., p.162. 4 Ibid. 5 Ibid., pp.191-205 and pp.212-233. 6 Julie Fish et al., Promoting Good Outcomes In Lesbian, Gay And Bisexual Cancer Care: A Qualitative Study Of Patientsâ&#x20AC;&#x2122;Experiences In Clinical Oncology (Leicester: DeMontfort University, 2018).p.7. 7 Ibid., p.11. 1 2

they “never felt treated as a set of cancer symptoms rather than as a whole person” or the “doctor never talked about me as if I wasn’t there”.8 We also know that nationally LGBT people are more likely to be affected by cancer risk factors. For example LGBT communities are more likely to smoke than the wider population. The Integrated Household Survey 2014 showed that 25.3% of gay and lesbian people smoked, compared to 18.4% of heterosexual people.9 Smoking causes cancers of the lung, liver, bladder, kidney and mouth amongst others.10 Whilst the research around LGBT people and drinking is slightly older and needs updating, this also indicates that LGBT people are more likely to misuse alcohol than the wider population. Stonewall’s Prescription for Change: lesbian and bisexual women’s health check and Gay and Bisexual Men’s Health Survey 2012 highlighted that a third of lesbian & bisexual women drink three times or more a week compared to 25% of women in general and 42% of gay & bisexual men drink three times or more a week compared to 35% of men in general.11 Excessive alcohol use causes a disease of the liver called cirrhosis, which can increase the risk of developing liver cancer. Excessive drinking also increases the risk of developing cancer in the mouth, upper throat, larynx, oesophagus, breast and bowel.12 The Emerging Picture on LGBT people with Cancer was published by Macmillan in 2013. It sought to bring together all available data on cancer inequalities for LGBT people into one place, summarising the needs and experiences of LGBT people affected by cancer. It highlighted numerous inequalities for LGBT people at the four main stages of cancer – diagnosis, treatment, post-treatment and end of life.13

Ibid. Action on Smoking and Health (ASH), Smoking And The LGBT Community (London: ASH, 2016).pp.1-2. 10 "How Smoking Causes Cancer", Cancer Research UK, 2016 <https://www.cancerresearchuk.org/aboutcancer/causes-of-cancer/smoking-and-cancer/how-smoking-causes-cancer> [Accessed 5 November 2018]. 11 See: Julie Fish and Ruth Hunt, Prescription For Change: Lesbian And Bisexual Women’s Health Check (London: Stonewall, 2008). and Stonewall, Gay And Bisexual Men’s Health Survey 2012 (London: Stonewall, 2012). 12 "How Alcohol Causes Cancer", Cancer Research UK, 2016 <https://www.cancerresearchuk.org/aboutcancer/causes-of-cancer/alcohol-and-cancer/how-alcohol-causes-cancer> [Accessed 5 November 2018]. 13 Macmillan Cancer Support, The Emerging Picture On LGBT People With Cancer (London: Macmillan, 2013). 8 9

Since the publishing of the Emerging Picture, more research has been undertaken into the experiences of LGBT people at a local level. The LGBTQ people affected by Cancer report by the Brighton and Hove LGBT Switchboard and commissioned by Macmillan focused on the experiences of LGBT people living with or affected by cancer in that region. The report identified a number of inequalities LGBTQ people with cancer experienced in terms of some aspects of the care, support and resources they received.14 The report also found numerous barriers LGBTQ people affected by cancer experienced in accessing support or information.15 Similarly, More Than A Diagnosis was published this year - a collaboration between Macmillan and DeMontfort University. The report focused on the creation of LGB-affirmative clinical spaces and how they can dramatically improve patient outcomes for LGB people living with cancer, as well as addressing social isolation through appropriately tailored health information.16 As of next year, new NHS guidelines will be coming into effect on the monitoring of sexual orientation. This will undoubtedly reveal new insights into the health inequalities LGBT people face.

Brighton and Hove LGBT Switchboard, LGBTQ People Affected By Cancer Report (Brighton: Macmillan Cancer Support, 2018).pp.48-53. 15 Ibid., p.45. 16 Fish et al., Promoting Good Outcomes In Lesbian, Gay And Bisexual Cancer Care: A Qualitative Study Of Patientsâ&#x20AC;&#x2122;Experiences In Clinical Oncology.pp.15-28. 14

LGBT Cancer Programme Merseyside This survey was undertaken as part of the LGBT Cancer Programme Merseyside. Macmillan is working in partnership with Sahir House to improve services and support to members of the LGBT community who are affected or could be affected by cancer in Merseyside. Sahir House are partnering in this work as they are able to bring their extensive reach into the LGBT communities of Merseyside, as well as their understanding of the impact that living with a long term condition (HIV) has on individuals, and their experience of providing practical and emotional support to members of the most marginalised communities in Merseyside. Over the next year, we will be working to identify the gaps in support that LGBT people affected by cancer will face and then start work that will help to bridge those gaps to ensure the cancer pathway meets the needs of each individual. The project will be hosting and supporting various events, developing and distributing resources, campaigning to raise the awareness and influence healthy lifestyles that could impact on the prevalence of cancer along with research into the gaps in services and provision, convening focus and steering groups to help influence change and training cancer professionals and volunteers to meet the needs of their LGBT patients.

Methodology The Survey The LGBT Health Survey Merseyside was launched on May 17th 2018 and ran until August 2nd 2018. The target group of the survey was people who: + Live in Greater Merseyside (encompassing boroughs of Liverpool, Sefton, Knowsley, St Helens, Wirral and Halton) + Self-identified as lesbian, gay, bisexual, transgender or having another minority sexual orientation or gender identity The survey is a mixture of online and in person responses. The primary method of response was online, at www.surveymonkey.co.uk/r/lgbtmerseyside. This link garnered 89.5% of responses. Paper copies of the survey were available and advertised alongside the SurveyMonkey link. This garnered the rest of our responses. The survey was circulated and promoted by stakeholders and partners. We utilised the groups and drop-ins hosted by and connected to Sahir House, as well as their connections in the community. We promoted the survey on social media as well as at outreach events. The responding period also corresponded with Liverpool Pride (weekend of 28th and 29th July) which was a large avenue for promotion. The questions focus on physical and mental wellbeing, experiences in healthcare settings, knowledge of cancer and relationship with cancer causing behaviours. Demographic information around gender, gender identity, age, ethnicity and borough of residence is also asked. The survey is entirely anonyomised and data collection was compliant with GDPR with no personal details stored for future contact. 10

Data Processing and Analysis The survey is a mixture of tick box selection and free-text comment boxes to gather both qualitative and quantitative data. Where appropriate, questions were tailored to match national health guidelines. Whilst the response rate was larger than expected, we still need to be cautious when interpreting the data. Our respondents were entirely self selected so it cannot be guaranteed to be fully representative of the LGBT population in Merseyside. No data exists on the makeup of the LGBT community, although the ONS (Office of National Statistics) is currently considering including sexual orientation in the 2021 census. Some boroughs of Merseyside have a much lower response rate than others with other boroughs possibly being overrepresented. This will mean that the data for some boroughs will not be as thorough as others. This is also true of BAME communities who are statistically under-represented in the survey. We will be undertaking additional work to capture the views of people from BAME groups. For the free-text comment responses, a selection can be found in this report. These have been chosen to reflect a representation of all the responses we received. A full list of the qualitative responses can be found as appendices to this report, as can a blank copy of the survey.

Demographics of respondents Gender Q1) What is your gender?

Male Female Prefer not to say Other

[Answered: 173 Skipped: 0] The respondents leaned slightly more female, with 47.98% identifying as female to 45.66% identifying as male. 1.16% preferred not to say and 5.2% of respondents identified in another way. In the free-text box for this question, the responses included identifying as Non-Binary and Agender.

Gender Identity Q2) Is your gender identity the same as the gender you were given at birth?

Yes No Prefer not to say

[Answered: 172 Skipped: 1] 88.95% of respondents were cisgendered (Someone who is not trans. ‘Cis’ is a Latin prefix meaning ‘on the same side’ and is used to describe someone who identifies with the gender they were assigned at birth), whilst 9.3% identified as having a gender identity that was different to the one in which they were assigned at birth. 1.74% chose not to answer.

Sexuality Q3) What is your sexuality?

Gay Man Lesbian Straight/Heterosexual

Bisexual Do not wish to disclose Other

[Answered: 173 Skipped: 0] 40.46% of respondents identified as a gay man, 26.59% identified as a lesbian, 15.03% as bisexual and 8.67% as heterosexual. Note that this does mean that 8.67% of the responses we received are not part of the LGBT community, as they may be a heterosexual trans person. This figure is at a similar level to those who identified as having a gender identity that was different to the one they were assigned at birth. 0.58% chose not to disclose and 8.67% of respondents identified as “Other”. However, it should be noted that some of those who selected ‘Other’ used the free-text box to identify as a gay woman as opposed to the term ‘Lesbian’ that was given as an option in the question. Further answers for ‘Other’ included Asexual, Pansexual and Queer.

Ethnicity Q4) What is your ethnicity? White British White Irish White Other Black or Black British - African Mixed White and Asian Mixed - Other Asian or Asian British - Pakistani Black or Black British - Carribean Mixed White and Black - Carribean Mixed White and Black - African Chinese

Prefer not to say Other

[Answered: 173 Skipped: 0] 92.49% of respondents were white, and 6.93% were BAME. Comparing this to the full population of Merseyside, this is slightly higher than the 91.8% who are estimated to be white.17 Note as well the wider Merseyside population data is from the 2011 census, so is likely to have undergone change since then. Of those who identified as BAME, the most common ethnic groups were ‘Black or Black British - African’, ‘Mixed White and Asian’ and ‘Mixed - Other’.

17 "Liverpool City Region Demographic Information", Merseytravel.Gov.Uk, 2018

<https://www.merseytravel.gov.uk/about-us/corporate-information/corporateresponsibility/Documents/Liverpool%20City%20Region%20Demographic%20Information%20March%2017.pdf> [Accessed 5 November 2018].p.10.

Age Q5) What is your age?

Below 20 20-30 31-40 41-50 51-60 61-70 Prefer not to say

[Answered: 173 Skipped: 0] The median age range of respondents was 41-50. This leans younger than the population of Merseyside more widely, which tends to have a population younger than the rest of the country.18 Note that the above choices were not the only ones offered. Age groups of ’71-80’, ’81-90’ and ‘90+’ were offered but not selected by any respondents.

Ibid., p.5.

Borough We also chose to ask which borough of Merseyside respondents were from to identify any trends specific to individual boroughs, as well as the spread of LGBT people across Merseyside.

Q6) What borough of Merseyside do you reside in?

Liverpool Sefton Knowsley St Helens

Wirral Halton Prefer not to say

[Answered: 173 Skipped: 0] 53.18% of respondents were from Liverpool, 6.94% were from Sefton, 8.67% were from Knowsley, 2.89% from St Helens, 20.23% from Wirral, 3.47% from Halton and 4.62% chose not to say. This is more Liverpool dominated than the wider Merseyside population, with only 33.77% of Merseysideâ&#x20AC;&#x2122;s total residents living in Liverpool.19 However, there is a significant body of evidence to suggest that LGBT people tend to populate densely in built-up metropolitan areas.20 This would be able to account for some of this disparity.

Ibid., p.3 Yvonne Doderer, "LGBTQs In The City, Queering Urban Space", International Journal Of Urban And Regional Research, 35.2 (2011), pp.431-436. 19 20

General Health We asked our respondents about the general physical and mental health of LGBT people in Merseyside.

Physical Health Q7) On a scale of 1 - 10 (with 1 being very poor and 10 being optimum), how would you rate your physical health at the moment? 70% 60% 50% 40% 30% 20% 10% 0% Total

Male Respondents Only

Female Respondents Only

Trans Respondents Only

Average Response

[Answered: 163 Skipped: 10] Amongst our total respondents, people rated their physical health out of 10 (with 10 being perfect and 1 being very poor) as 6.4. It should be noted that on the online version of the survey decimal answers are prompted and allowed, whereas on the paper version of the survey this isnâ&#x20AC;&#x2122;t immediately obvious or prompted. This may have changed the responses some respondents of the paper survey chose to give. This result is broadly similar amongst those who identified as male and female in Q1. Amongst those who stated in Q2 that they had a gender identity different to the one they were assigned with at birth the average response was significantly lower at 5.1.

Q7) On a scale of 1 - 10 (with 1 being very poor and 10 being optimum), how would you rate your physical health at the moment?? 80.00% 70.00%

60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Liverpool

Wirral

Sefton

Average Response

St Helens

Halton

Knowsley

Region Wide Average

[Answered: 163 Skipped: 10] There is some regional variation in our respondents ratings of their physical health. Respondents from Liverpool rated their physical health at an average of 6.8, compared to 6.1 from respondents from Wirral, 7.4 from Sefton, 4.6 from St Helens, 5.3 from Halton and 5.4 from Knowsley. This is compared to a regionwide average of 6.4. It should be noted that in some boroughs we got fewer responses than others so the data will not be as rich.

Physical Activity Q8) How often do you do any form of physical activity? (e.g. walking, cycling, swimming, gardening, jogging...) Very frequently (5-7 times per week)

Frequently (4 times per week)

Average (3 times per week)

Infrequently (1-3 times per week)

Never (0 times per week) Total

24.26

Male Respondents Only

25.64

Female Respondents Only Trans Respondents Only

23.08

27.22

29.49

20.71

23.08

23.46

18.52

28.4

33.33

4.73

19.23 2.56 23.46 13.33

6.17 13.33

[Answered: 169 Skipped: 4] Respondents gave their level of physical activity in a given week. Guidelines issued by the Chief Medical Officers (CMOs) of England, Scotland, Wales and Northern Ireland state that adults should be active daily. The guidelines state that over a week, activity should add up to at least 150 minutes of moderate intensity activity in bouts of 10 minutes or more â&#x20AC;&#x201C; and that the most common way to approach this is to do 30 minutes on at least 5 days a week.21 We sought to mirror the British Heart Foundation questioning on physical activity, including their definition of exercise. Whilst it is difficult to ascertain from our survey the duration of the exercise activity from our respondents, as we do not ask, if we were to assume that it meets the half an hour guideline from the

British Heart Foundation, Physical Activity Statistics 2015 (Oxford: British Heart Foundation Centre on Population Approaches for Non-Communicable Disease Prevention. Nuffield Department of Population Health, 2015).p.14. 21

British Heart Foundation then those who selected Very Frequently (5-7 times a week) would constitute as meeting the CMO guidelines. This would mean that 24.26% of respondents meet the national activity guidelines, much lower than the 67% of adults in Englandâ&#x20AC;&#x2122;s wider population who meet them.22 Note that there is some differences in the levels of physical activity, with male respondents having a level of activity that is above average for the wider community, whilst female and Trans respondents had a below average level of physical activity.

Ibid., pp.15-17.

Mental Health Q9) In the past 24 months, have you experienced poor mental health? (e.g. stress, anxiety, depression, eating disorder...) Yes

72.78%

Total

27.22%

73.08%

Male Respondents Only

26.92% 69.14%

Female Respondents Only Trans Respondents Only

30.86% 93.33% 6.67%

[Answered: 169 Skipped: 4] Respondents answered if they had experienced poor mental health in the last two years. 72.78% of respondents said they had, with 27.22% saying they had not. For this question, amongst those who had indicated in Q1 that they identified as male, 73.08% had experienced poor mental health in the preceding two years. This is compared to 69.14% amongst those who identified as female. Amongst those who in Q2 identified as having a gender identity different to that in which they were assigned with at birth, 93.33% had experienced poor mental health in the last 24 months. Whilst difficult to make direct comparisons due to wording and question parameter differences in different research, this result indicates a much higher prevalence of mental health issues in the LGBT community compared to the wider population. Approximately 1 in 4 people in the wider population of the UK

will have experienced a mental health problem in the last year.23 This is compared to our results of nearly 3 in 4 in the last 24 months, including 9 in 10 amongst Trans respondents.

Steven Marwaha and others, "The Prevalence And Clinical Associations Of Mood Instability In Adults Living In England: Results From The Adult Psychiatric Morbidity Survey 2007", Psychiatry Research, 205.3 (2013), pp.262268. 23

Being LGBT in healthcare settings In order to learn more about LGBT people in Merseysideâ&#x20AC;&#x2122;s experiences in healthcare settings, we asked our respondents a series of questions about their disclosing of their sexuality or gender identity, their experiences of discrimination and their encountering with resources relevant to LGBT people.

Disclosure of sexuality Q11) Are you out to medical professionals (excluding those in sexual health) about your sexuality?? Yes

75.32%

Total

Male Respondents Only

Female Respondents Only

24.68% 88.73% 11.27% 66.23% 33.77%

[Answered: 158 Skipped: 15] Our respondents indicated that 75.32% of them were out to medical professionals about their sexuality, with 24.68% indicating that they were not. The nuances of this data reveal a more complex picture. For this question, amongst those who in Q1 identified as male, 88.73% were out to medical professionals and 11.27% were not. Whereas amongst those who identified as female in Q1, 66.23% were out to medical professionals and 33.77% were not. This is a difference of 22.5% between those who identify as male and female who are comfortable disclosing their sexuality to a medical professional. 24

Q11) Are you out to medical professionals (excluding those in sexual health) about your sexuality? 120.00%

100.00%

80.00%

60.00%

40.00%

20.00%

0.00% Liverpool

Wirral

Sefton Yes

St Helens

Halton

Knowsley

Region Wide Average

[Answered: 158 Skipped: 15] There is some regional variation on disclosing sexuality to a medical professional. 75.86% of respondents from Liverpool stated they were out to medical professionals about their sexuality. This is compared to 67.74% of respondents from Wirral, 83.33% from Sefton, 100% from St Helens, 66.67% from Halton and 76.92% from Knowsley. This is against a region-wide average of 75.32%. However, it should be noted that in some boroughs we got fewer responses than others so the data will not be as rich.

Q13) Are you out to sexual health professionals about your sexuality? Yes

74.34%

Total

Male Respondents Only

Female Respondents Only

25.66% 88.57% 11.43% 65.75% 34.25%

[Answered: 152 Skipped: 21] Our respondents indicated that 74.34% of them had disclosed their sexual orientation to sexual health professionals, with 25.66% indicating that they had not. The responses to this question mirror that of Q11. Amongst those who identify as male in Q1, 88.57% of respondents indicated that they are out to sexual health professionals about their sexuality and 11.43% were not. Amongst those who identify as female in Q1, 65.75% of respondents are out to sexual health professionals and 34.25% are not. This is a difference of 22.82% between people who identify as male and female on willingness to disclose their sexuality to a sexual health professional.

Q13) Are you out to sexual health professionals about your sexuality? 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Liverpool

Wirral

Sefton Yes

St Helens

Halton

Knowsley

Region Wide Average

[Answered: 152 Skipped: 21] There is some regional variation on disclosing sexuality to sexual health professionals. 81.79% of respondents in Liverpool indicated that they had disclosed their sexuality to sexual health professionals, compared to 58.06% in Wirral, 91.76% in Sefton, 66.67% in St Helens, 33.33% in Halton and 69.23% in Knowsley. This is against a region-wide average of 74.34%. It should be noted that in some boroughs we got fewer responses than others so the data will not be as rich.

Disclosure of gender identity Note that in the questions below, respondents who answered â&#x20AC;&#x2DC;Yesâ&#x20AC;&#x2122; to Q2 have been filtered out. The responses remaining are from those who indicated that they have a gender identity that is different to the one in which they were assigned at birth.

Q12) If applicable, are you out to medical professionals (excluding those in sexual health) about your gender identity? 7%

21% No Yes Not sure if applicable

72%

[Answered: 156 Skipped: 17] Amongst our remaining respondents, 71.43% had disclosed their gender identity to medical professionals and 21.43% had not. 7.14% were not sure if this was applicable.

Q14) If applicable, are you out to sexual health professionals about your gender identity?

21%

29%

No Yes

Not sure if applicable Not applicable 43%

[Answered: 156 Skipped: 17] Amongst our remaining respondents, 42.86% were out to sexual health professionals about their gender identity, and 28.57% were not. 21.43% believed it to not be applicable, and 7.14% were not sure if it was applicable.

Discrimination Q15) Have you ever experienced or witnessed discrimination or poor treatment from any medical professional due to sexuality or gender identity? Yes

No 33.54%

Total Male Respondents Only

66.46%

23.94% 76.06% 42.86%

Female Respondents Only

57.14% 57.14%

Trans Respondents Only

42.86%

[Answered: 158 Skipped: 15] Amongst our total respondents, 33.54% indicated that they had witnessed or experienced discrimination or poor treatment in a medical setting whereas 66.46% had not. For this question amongst those who identified as male in Q1, 23.94% indicated that they had experienced or witnessed discrimination or poor treatment in a medical setting due to their sexuality or gender identity, whereas 76.06% said they had not. Amongst those who identified as female in Q1, 42.86% had experienced or witnessed discrimination or poor treatment and 57.14% had not. This is a difference of 18.92% between those who identify as male and female. Amongst those who identified in Q2 that they had a gender identity different to the one they were assigned with at birth, 57.14% had experienced or witnessed discrimination or poor treatment in a medical setting and 42.86% had not.

Experiences of discrimination For those who answered yes to Q15, we then had an open-ended textbox question to provide more information on the discrimination or poor treatment they had witnessed or experienced due to sexual orientation or gender identity. Below is a selection of these responses. These are repeated as they were submitted:

Assumption that I am in a heterosexual relationship. Ignoring questions and concerns relating to my sexuality.

Several times I have been told if I decide to be with a man I need to tell me doctor of change of circumstances. Another time I was told when I stop being with my 7 and a half year partner to go on contraception.

Unwillingness from a nurse to discuss if I needed a cervical smear as I had never had a heterosexual relationship. I made it clear that I was a lesbian but she failed to acknowledge this. She told me to come back when I was "ready for a relationship". This was many years ago. Also a few years back a doctor at the Women's Hospital (I attended as an emergency following complications from an op) asked me about sexual health but made the presumption I was heterosexual - seemed embarrassed when I told her my sexuality.

when going for smears or gynae matter- Hetronormative treatment

Repeatedly being asked if I could be pregnant. Confusion about whether or not I needed to have cervical smear tests.

Rudeness around sexuality during pre-HIV test consultation

They assume I am promiscuous and have talked to me in a derogatory and judgemental manner, although I am an ex health professional and fully understand how to protect myself and my sexual health

Treated as a male by a nurse during a hospital admission. As a nurse I have witnessed discrimination against patients due to their sexuality

Had my GP laugh in my face repeatedly, tell me I was stupid, laughed some more then flat out refused when I asked for blood tests well taking hormones DIY.

wouldnt prescibe me skin medication for risk of getting pregnant depite being in a long term relationship with a woman

Forced pregnancy test on lesbian female before allowing any pain relief to be administered in A&E resulting in a wait of 5 hours before any pain relief given.

A trans woman being misgendered as a male (even though she was passing rather well) at hospital. They called her Mr, and used her birth name instead of her preferred name.

Asked to do pregnancy test - even though stated sexuality a few times & doctor was homophobic

People being laughed at/not offered certain female cancer checks

Inappropriate questions from nurse in hospital about which genitals I have.

Heterosexual presumption in smear test

Not being given the right information, heteronormative assumptions, visible discomfort from doctors when discussing it

Withholding information Q17) Have you ever withheld information from a medical professional through fear of a negative reaction to your sexuality or gender identity? Yes

Total Male Respondents Only

No 27.22% 72.78%

19.72% 80.28% 32.47%

Female Respondents Only Trans Respondents Only

67.53% 21.43% 78.57%

[Answered: 158 Skipped: 15] Amongst our total respondents, 27.22% indicated that they had withheld information from a medical professional through fear of a negative reaction to their sexuality or gender identity. 72.78% had not. For this question, amongst those who identified as male in Q1 19.72% had withheld information from a medical professional through fear of a negative reaction to their sexual orientation, and 80.28% had not. Amongst those who identified as female in Q1, 32.47% had withheld information and 67.53% had not. This is a difference of 12.75%. Amongst those who identified in Q2 that they had a gender identity different from the one that they were assigned with at birth, 21.43% had withheld information from a medical professional through fear of a negative reaction to their sexuality or gender identity and 78.57% had not.

Experiences of withholding information For those who answered yes to Q17, we then had an open-ended textbox question to explain what made them fear a negative reaction to their sexuality or gender identity to the point where they would withhold information from a medical professional. Below is a selection of these responses. These are written as submitted: A lot of cancer treatment is generic it was easier to go along with what was on offer as opposed to what I needed regarding my sexuality They made the assumption i had a girlfriend and I felt too awkard to correct them.

Fear of judgement So not to be judged about my sexuality I feel like I see more people standing outside straight pubs smoking than I do gay pubs

I experienced domestic abuse by my (ex)wife. I was having a lot of 'accidents' and my mental health was suffering. I was never asked about my injuries by either my GP or at A&E. This went on for over 10 years. I also didn't offer the information as often my (ex) wife would be with me and domestic abuse screening was not offered to me. I didn't tell my gp until after the relationship had ended and I needed help with my mental health. Actually, I ended up self-referring into IAPT and was diagnosed with PTSD. I got a lot of help from the therapist I was seeing, he was fantastic and I felt I could be totally open with him, so this isn't one sidedI;m not against health professionals, I just don't think they are as aware of the prevalence of domestic abuse in same-sex or inter-sex relationships.

I was uncomfortable going to my GP about my gender identity and went private with therapy to start

I just didn't want the rolled eyes. I just wanted a full STI check without the patronising 'lesson' on sexual health

Concerns would receive sub standard treatment or would be judged

I was unconfortable with the persons probing me for every detail where as my GP I can talk to and be relaxed about everything I have to say

Transphobic GP

I didn't know what reaction I'd get, I just said partner instead of boyfriend

Fear of being treated differently, looked down upon I've attended therapy on numerous occasions and never told any therapist that I identify as LGBT although it is a massive part of my life and always dance around the topic and any speak of my relationships

Just wasn't sure how it would be taken and didn't think it was relevant to the issue

Resources targeted to LGBT people Q19) In a medical setting, have you seen any specific posters or information for patients that are specifically targeted towards or include lesbian, gay or bisexual people (for example, by using images of same-sex couples)? Yes

38.22%

Total

61.78% 45.07%

Male Respondents Only

54.93% 32.89%

Female Respondents Only

67.11%

[Answered: 157 Skipped: 16] Amongst our total respondents, 38.22% had seen specific information targeted towards patients who are Lesbian, Gay or Bisexual. 61.78% had not. Amongst those who identified as male in Q1, 45.07% had seen specific information targeted towards LGB patients, and 54.93% had not. Amongst those who identified as female in Q1, 32.89% had seen resources targeted at LGB patients and 67.11% had not. Between those who identify as male and female, this is a difference of 12.18%.

Q19) In a medical setting, have you seen any specific posters or information for patients that are specifically targeted towards or include lesbian, gay or bisexual people (for example, by using images of same-sex couples)? 60.00% 50.00% 40.00%

30.00% 20.00% 10.00% 0.00% Liverpool

Wirral

Sefton Yes

St Helens

Halton

Knowsley

Region Wide Average

[Answered: 157 Skipped: 16] There is a slight difference between boroughs on having seen LGB specific resources. In Liverpool, 41.38% of people had seen resources targeted at LGB people, compared to 28.13% in Wirral, 41.67% in Sefton, 33.33% in St Helens, 25% in Halton and 53.85% in Knowsley. This is compared to a region wide average of 38.22%. It should be noted that in some boroughs we got fewer responses than others so the data will not be as rich.

Q20) In a medical setting, have you seen any specific posters or information for patients that are specifically targeted towards or include trans people? Yes 10%

No 90%

[Answered: 156 Skipped: 17] Amongst our total responses, 9.62% of people had seen specific information targeting Trans patients. Note that this roughly matches up with the number of respondents in Q2 who identified themselves as having a different gender identity to the one in which they were assigned with at birth.

Q21) Do you feel you personally would benefit from information/resources tailored to LGBT people?

No 25%

Yes 75%

[Answered: 156 Skipped: 17] 75% of our total respondents feel that they would personally benefit from resources/information tailored to LGBT people. 25% did not.

Q22) Do you know somebody who you feel would benefit from information/resources tailored to LGBT people?

No 19%

Yes 81%

[Answered: 155 Skipped: 18] 81.29% of our total respondents felt that they knew somebody who would benefit from resources/information tailored to LGBT people. 18.71% did not.

Q23) Have you ever been given information that is relevant to your sexuality or gender identity? Yes

34.39%

Total

65.61% 45.07%

Male Respondents Only

Female Respondents Only

54.93% 25.00% 75.00%

[Answered: 157 Skipped: 16] Amongst our total respondents, 34.39% had been given information relevant to their sexuality or gender identity. 65.61% had not. For this question, amongst those who identified as male in Q1 45.07% had been given information that is relevant to their sexuality or gender identity, compared to 25.07% for those who identified as female. This is a difference of 20.07% between those who identify as male and female.

Q23) Have you ever been given information that is relevant to your sexuality or gender identity? 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Liverpool

Wirral

Sefton Yes

St Helens

Halton

Knowsley

Region Wide Average

[Answered: 157 Skipped: 16] Similar to Q19, there is a regional difference on being given information relevant to gender identity or sexuality. 37.93% of people in Liverpool had, compared to 21.88% for Wirral, 33.33% in Sefton, 66.67% in St Helens, 20% in Halton and 53.85% in Knowsley. This is compared to a region-wide average of 34.39%. It should be noted that in some boroughs we got fewer responses than others so the data will not be as rich.

Q24) Have you ever been given medical information that is not relevant to you due to your sexuality or gender identity? Yes

No 47.13% 52.87%

Total

44.29%

Male Respondents Only

55.71% 49.35% 50.65%

Female Respondents Only 35.71%

Trans Respondents Only

64.29%

[Answered: 157 Skipped: 16] Amongst our total respondents, 47.13% of people had been given medical information that was not relevant to them due to their sexuality or gender identity, and 52.87% had not. For this question, amongst those who identified as male in Q1, 44.29% had been given information that was not relevant to them due to their sexuality or gender identity. This compares to 49.35% amongst those who identify as female. This is a difference of 5.06%. Amongst those who identified in Q2 that they had a gender identity different from the one in which they were assigned with at birth, 35.71% had been given information that was not relevant to them due to their sexuality or gender identity, and 64.29% had not.

Your experiences of cancer Screening We asked our respondents if they been for a cervical or prostate cancer screening (if applicable) We chose not to filter these results by those who had previously identified themselves as male or female, as: • We know that many trans men will have a cervix and many trans women will have a prostate. There is evidence to suggest that the cisnormative (the assumption that all human beings have a gender identity that matches the sex they were assigned at birth) assumptions that male=prostate female=cervix contributes to a much lower screening uptake amongst trans people. • We also know that for a variety of reasons those born with a cervix or prostate may have to have them removed at some point in their lifetimes. As such, we had ‘Not Applicable’ options for both questions to allow those without a cervix or prostate to opt out of the question that is not relevant to them without selecting ‘No’ and skewing the data. • We also had a ‘Not sure if applicable’ option to allow for those who may not know if they have a cervix or a prostate, as we know that with them being medical terminology that not everyone may know which one they have, to ensure they do not just answer ‘No’. However, it should be noted that whilst we have made every effort to ensure that those who it is not relevant to did not answer the question, some people who do not have a cervix/prostate may still have answered ‘No’ on those questions. We did filter for the ages of the national screening programmes. The answers displayed below are filtered - for Q25, based on the answers given in Q5 all ages are filtered out apart from those between 50 and 70 to align with the national breast screening programme.24 For Q26, the responses of all those

"Breast Screening: Programme Overview", GOV.UK, 2015 <https://www.gov.uk/guidance/breast-screeningprogramme-overview> [Accessed 5 November 2018]. 24

aged below 20 have been filtered out. Note that the cervical cancer screening programme is for those that are 25 and over,25 whilst in Q5 ages are given in 10 year ranges so some not eligible may have answered the question. For Q27, there is no current national screening programme for prostate cancer so no ages are filtered out. The question was designed to be exploratory and measure general uptake or knowledge of cancer screening.

Q25) If applicable, have you ever had a breast cancer screening?

Yes

Amongst eligible respondents

20%

40%

60%

80%

100%

[Answered: 155 Skipped: 18] Our respondents (with ‘Not Applicable’ and ‘Not sure if applicable’ excluded, as well as those previously mentioned outside of the breast screening programme age) indicated that 73.68% of them had at some point been for a breast cancer screening, with 26.32% indicating they hadn't. The national average for breast cancer screening uptake is 71.1%.26 Coverage is defined as the percentage of the eligible population who have had a test with a recorded result within the last three years.27

"Cervical Screening: Programme Overview", GOV.UK, 2015 <https://www.gov.uk/guidance/cervical-screeningprogramme-overview> [Accessed 5 November 2018]. 26 NHS England, Breast Screening Programme, England - 2016-17, PAS (London: National Health Service, 2018).p.1. 27 Ibid., p.4. 25

Whilst our respondents percentage is higher than the national average the question stipulates across a lifetime rather than in the prior three years, meaning more research is needed to properly identify breast screening uptake in the LGBT community.

Q26) If you are a person with a cervix, have you been for a cervical screening?

Yes

Amongst eligible respondents

20%

40%

60%

80%

100%

[Answered: 154 Skipped: 19] Our respondents (that are eligible for the national cervical screening programme, so those between the ages of 25 and 64, and excluding those who selected ‘Not Applicable and ‘Not sure if applicable’) indicated that 74.65% of them had attended a cervical screening, with 25.35% of them indicating they had not. This is against a national average of 72%.28 As previously, the question stipulates across a lifetime rather than in the time window for screening (every

"PHE Concern As Cervical Cancer Screening Uptake Continues Decline", Pulse Today, 2018 <http://www.pulsetoday.co.uk/clinical/clinical-specialties/cancer/phe-concern-as-cervical-cancer-screening-uptakecontinues-decline/20035618.article> [Accessed 5 November 2018]. 28

3-5 years, depending on age) so further research would need to be undertaken to identify in full the cervical screening uptake in the LGBT community.

Q27) If you are a person with a prostate, have you ever had a screening for prostate cancer?

Yes

Amongst those applicable

20%

40%

60%

80%

100%

[Answered: 155 Skipped: 18] Our respondents (excluding those who selected ‘Not Applicable’ and ‘Not sure if applicable’) indicated that 22.67% of them had at some point attended a prostate cancer screening, with 77.33% indicating they had not. As there is no national prostate cancer screening programme, there is no reliable data on the national uptake of prostate cancer screenings. 1 in 8 men will get prostate cancer at some point in their lives. Contrary to some beliefs, there is no evidence to suggest that gay or bisexual men are more or less likely to get prostate cancer.29 Trans women who still have a prostate can also get prostate cancer.30

"Prostate Facts For Gay And Bisexual Men", Prostate Cancer UK, 2018 <https://prostatecanceruk.org/prostateinformation/living-with-prostate-cancer/gay-and-bisexual-men> [Accessed 5 November 2018]. 30 "Can Trans Women Get Prostate Cancer?", Prostate Cancer UK, 2018 <https://prostatecanceruk.org/prostateinformation/are-you-at-risk/trans-women-and-prostate-cancer> [Accessed 5 November 2018]. 29

Knowledge of cancer We asked our respondents which out of a series of cancers they had ever been given information about. The question allowed for multiple answers to be selected, and had an â&#x20AC;&#x2DC;Otherâ&#x20AC;&#x2122; section with free-text box to allow for additional answers not listed.

Q28) Which of the following cancers have you ever been given information about? Breast Cancer

41.74%

Cervical Cancer

38.26%

Skin Cancer

33.91%

Prostate Cancer

23.48%

Lung Cancer

19.13%

Bowel Cancer

19.13%

Other Oral cancer (s) Rectal Cancer Liver Cancer Bladder Cancer

17.39% 10.43% 7.83% 7.83% 6.96%

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00%

[Answered: 115 Skipped: 58] Of all of the options available, no type of cancer had information given to over 50% of our respondents indicating a general low level of knowledge about cancer across the board. Our respondents were most likely to have been given information about breast cancer, with 41.74% of people indicating that they had. 38.26% of respondents had been given information about cervical cancer, and 33.91% had been given information about skin cancer. For the rest of the options given, none reached above a quarter of respondents selecting that they had been given information about them.

LGBT people and smoking Prevalence of smoking We asked respondents if they were smokers and how frequently they smoked.

Q29) Do you currently smoke tobacco? Daily

Total

Male Respondents Only

Female Respondents Only

Trans Respondents Only

Occassionally

Have stopped/ex smoker

14.10% 12.18%

14.29%

10%

23.72%

18.57%

13.16% 13.16%

14.29% 14.29%

28.95%

21.43%

Never

50%

57.14%

44.74%

50%

[Answered: 156 Skipped: 17] 26.28% of our respondents identified as a smoker sometimes or frequently. This is much higher than the national average amongst the wider population, and slightly higher than the national average for LGBT people.31 23.72% of respondents identified as having stopped smoking or an ex-smoker. 50% of respondents had never smoked. Amongst those who identified as female in Q1, 26.32% said they smoked sometimes or frequently compared to 24.29% who identified as male. Amongst those who identified in Q2 that they had a gender identity different to the one in which they were assigned with at birth, 28.58%

ASH, Smoking And The LGBT Community.pp.1-2.

smoked daily or occasionally, with 21.43% indicating that they had quit smoking and 50% having never smoked.

Frequency of smoking Q30) If applicable, how many cigarettes do you smoke a day? 1 to 5

6 to 10

11 to 15

16 to 20

21+

Total

51.35%

8.11% 16.22%

Male Respondents Only

52.94%

0% 17.65%

Female Respondents Only

Trans Respondents Only

47.06%

11.76%

50.00%

17.65%

25.00%

19%

17.65%

5.41%

11.76%

23.53%

25.00%

0% 0

[Answered: 151 Skipped: 22] We asked respondents how many cigarettes they smoked a day, if applicable. If we exclude those who said it was not applicable (presumably as they did not smoke) - 51.35% of respondents smoke 1-5 cigarettes a day, 8.11% smoke 610 cigarettes a day, 16.22% smoke 11-15 cigarettes a day, 18.92% smoke 1620 cigarettes a day and 5.41% smoke over 20 cigarettes a day. This indicates that, as well as the higher level of smoking previously mentioned, those who do smoke are also more likely to smoke frequently.

Smoking and the LGBT community We wanted qualitative feedback from our respondents on whether they thought smoking was more or less prevalent in the LGBT community, and if so why they thought that was.

Q31) In your opinion, is smoking more or less prevalent in the LGBT community?

33% More Less 64%

The Same 3%

[Answered: 152 Skipped: 21] 32.89% of our respondents indicated that they thought smoking was more prevalent in the LGBT community than in the non-LGBT community, with 3.29% thinking it was less prevalent and 63.82% of people thinking it was at the same level. We asked those who indicated that it was more or less prevalent to say why they thought that is the case. Below is a word cloud based upon these responses:

Below is a selection of their responses. All are repeated as submitted. It seems to be part of the culture - particularly those who are regularly on the 'scene', it is seen as the thing to do - grab a drink, head out for a cigarette and a chat. Also most bars have the music too loud to chat, so the only place to chat is in the smoking area. I know many 'social' smokers, who only smoke at bars.

it seems that all gay men smoke

Lot of the scene based around bars and clubs

We are encouraged to use clubs and bars as places to meet and selfidentify: you are more likely to drink and/or smoke in such places so therefore...

I feel like I see more people standing outside straight pubs smoking than I do gay pubs Health education in the LGBT community seems to poorer than in the general population. Less healthy choices coupled to lower income, lower self esteem and social isolation Poorer mental health among LGBT community usually results in higher rates of risky behaviours

LGBT people and alcohol Prevalence of drinking Q33) Do you drink alcohol? No

Total

Yes

16.77%

83.23%

Male Respondents Only 11.59%

Female Respondents Only

Trans Respondents Only

88.41%

19.74%

80.26%

35.71%

64.29%

[Answered: 155 Skipped: 18] 83.23% of our respondents indicated that they drunk alcohol, with 16.77% saying they did not. There is a slight but noticeable statistical difference between those who identified as male and female in Q1, with 88.41% of those who identify as male indicating that they drank compared to 80.26% of those who identify as female. This is a difference of 8.15%. Amongst those who indicated in Q2 that they had a gender identify different to the one in which they were assigned with at birth, 64.29% indicated that they drink alcohol compared to 35.71% who do not.

Frequency of drinking Q34) If yes, how many times a week do you drink? 7 times a week

4-6 times a week

Total 4.72%13.39%

2-3 times a week

37.80%

Male Respondents Only 6.56% 14.75%

Female Respondents Only3.33% 10.00%

Trans Respondents Only0.00% 11.11%

37.70%

40.00%

33.33%

Once a week

44.09%

40.98%

46.76%

55.56%

[Answered: 154 Skipped: 19] Amongst our total respondents [with those who selected â&#x20AC;&#x153;Not applicableâ&#x20AC;? filtered out presumably as they do not drink]: 4.72% of people indicated they drank 7 times a week, with 13.39% indicating they drank 4-6 times a week, 37.80% drinking 2-3 times a week and 44.09% drinking once a week. Amongst respondents who identified as male in Q1 heavy drinking was more common, with 6.56% stating they drank 7 times a week, 14.75% drinking 4-6 times a week, 37.70% drinking 2-3 times a week and 40.98% drinking once a week. This is compared to those who identified as female where 3.33% drank 7 times a week, 10% drank 4-6 times a week, 40% drank 2-3 times a week and 46.76% drank once a week. Amongst those who in Q2 stated that they had a gender identity different to that in which they were assigned at birth, 11.11% stated they drank 4-6 times a week, 33.33% drank 2-3 times a week and 55.56% drank once a week.

Alcohol and the LGBT community We wanted qualitative feedback from our respondents on whether they thought drinking was more or less prevalent in the LGBT community, and if so why they thought that was.

Q35) Do you think excessive alcohol usage is more or less prevalent in the LGBT community?

More 48%

51%

Less The Same

47.71% of our respondents indicated that they thought that alcohol usage was more prevalent in the LGBT community, with 51.63% thinking it was the same level and 0.65% thinking it was less prevalent. We asked those who indicated that it was more or less prevalent to say why they thought that is. Below is a word cloud based upon these responses.

Below is a selection of their responses. All are repeated as written. The only places it's normal to meet other LGBT+ people without needing to do the awkward "oh my god you're amazing and cool but I don't know if you're attracted to people of my gender or not" (which you have to go a long time without knowing so that it doesn't sound creepy when you ask, may I add) is at gay bars. Yknow, where alcohol is served. We need some gay cafĂŠs and restaurants and such so that the under 18s can find others like them without having to be out to everyone to do so.

Party lifestyle. Social isolation. People going out to try and meet people/date as dating apps have an impact on peoples expectations of sexual relationships

More hedonistic society, with currently a lesser chance of children requiring looking after - lets face it, accidental pregnancies are not really a concern in the gay community.

The social settings in which LGBT people find each other are often venues that sell alcohol Due to gay and lesbian bars being a more welcoming place and therefore more likely to drink when in this environment. Mix this with the potential for issues surrounding sexuality making life difficult to cope with, alcohol can become a crutch to help. Mental health issues, discrimination. People self-medicate. Higher than average alcohol consumption is more prevalent in the LGBT community because its part of the culture and there is a higher prevalence of mental health issues. One of the ways I used to drown out dysphoria, some of my other trans friends used alcohol or other drugs in the same way. Alcohol can combat shyness. Inhibitions get lost and confidence can grow after a few drinks. Due to rising rents, most LGBT spaces are now bars or clubs. There are few places you can mix with other LGBT people that don't involve alcohol.

LGBT people and drugs Prevalence of drug use We asked our respondents about their use of non-prescription drugs. Before this question, we included a supporting note reminding respondents that the survey is entirely anonymous, designed to improve services without responses tied to individuals. This was to encourage answers to be honest and open as possible. We also chose not to specify drugs or on legality, instead allowing to the respondents own interpretation on what drug use is.

Q37) Do you use non-prescription drugs as part of your social or home life? No

Total

Male Respondents Only

Female Respondents Only

Trans Respondents Only

Yes

81.41%

75.71%

86.84%

92.86%

18.59%

24.29%

13.16%

7.14%

[Answered: 156 Skipped: 17] 18.59% of respondents indicated that they did use non-prescription drugs as part of their social or home life, whilst 81.41% did not. This compares to 9% for the national population.32 For this question, amongst those who identified as male in Q1, 24.29% of respondents said they did use non-prescription drugs as part of their social or home life whereas 75.71% said they did not. Amongst

Home Office, Drug Misuse: Findings From The 2016/17 Crime Survey For England And Wales (London: HM Government, 2017).pp.1-3. 32

those who identified as female in Q1, 13.16% said they did whereas 86.84% said they did not. This is a difference of 11.13%, with those who identify as male being more likely to use non-prescription drugs as part of their social or home life. For this question, amongst those who identified in Q2 as having a gender identify different to the one in which they were assigned at birth, 7.14% said that they were a drug user whereas 92.86% said they did. However, it should be noted that the lower rate of response amongst trans people compared to the rest of the LGBT community means that the data will not be as thorough.

Types of drugs used We asked our respondents who in the previous question identified that they did use drugs as part of their social or home life which ones they used. The responses included GHB, Cannabis, Ecstasy, LSD, Cocaine, MDMA, Mephedrone and various â&#x20AC;&#x153;legal highsâ&#x20AC;?.

LGBT people and tanning Prevalence of self-tanning Q39) Do you currently use a sunbed? Daily Occasionally (weekly) Infrequenly (less than weekly but more than monthly) Never Total Male Respondents Only Female Respondents Only

Daily Occasionally (weekly) Infrequenly (less than weekly but more than monthly) Never

Female Respondents Only 1.32% 3.95%

Male Respondents Only 0.00% 1.43%

0.64% 2.56%

5.26%

5.71%

5.13%

89.47%

92.86%

91.67%

Total

[Answered: 156 Skipped: 17] Amongst our respondents, 8.33% indicated that they used a sunbed sometimes or frequently. Amongst those who identified as male in Q1, 7.14% of respondents indicated that they used the sunbeds sometimes or frequently. This is compared to 10.53% amongst those who identified as female. Note that nobody who answered in Q2 that they had a gender identity that was different to the one in which they were assigned with at birth said that they used the sunbeds. However, it should be noted that the lower rate of response amongst trans people compared to the rest of the LGBT community means that the data will not be as thorough.

Self-tanning and the LGBT community We wanted qualitative feedback from our respondents on whether they thought sunbed use was more or less prevalent in the LGBT community, and if so why they thought that was.

Q40) Do you think sunbed usage is more or less prevalent in the LGBT community?

14% 1%

More Less

56%

29%

The Same Not sure

[Answered: 155 Skipped: 18] 14.19% of our respondents indicated that they thought that sunbed usage was more common in the LGBT community, with 1.29% thinking it was less common, 29.03% thinking it was about the same and 55.48% indicating that they werenâ&#x20AC;&#x2122;t sure. We asked those who indicated that it was more or less prevalent to say why they thought that is. Below is a word cloud based upon these responses:

Below is a selection of their responses. All are repeated as submitted. We are encouraged to think of beautification as part of our self identity and also just spend money. Gayness - and but to a far lesser extent LB and T - is as much economic term as a social one - you are gay not when you have sex with the same sex - that is being homosexual - but when you spend money to self-identify as doing so. Certainly among younger gay men, there does seem to be a prevalence in sunbed use. A tan is perceived as sign of health + wellbeing, media influence Body image, previous body shame/self resentment Possibly higher in gay men but lower in lesbians? Thats just a guess though. Some of this may be because of pressure on younger gay men to look a certain way. Historicallu young lesbians haven't had the same pressure but i suspect this is changing The seems to be a culture of this in liverpool Perception by some gay men is tanned skin equals beauty and healthiness I do see younger people on the gay scene who clear have used a sunbed (and tanning products) Gay men are attracted visuals. If you look your best, you are more likely to attract potential partners.

Comments on the survey We concluded the survey with an open-ended question asking if thereâ&#x20AC;&#x2122;s any further comment the respondent would like to make or if there was anything they would like to add to the survey. Below is a selection of the comments we received on the survey. All are repeated as submitted. [Answered: 49 Skipped: 124] Not clear why questions of class were not included in this survey. These issues are relevant to the LGBTQI community. I have been treated better than fellow LGBTQI people because I am perceived by the medical profession as middle class and educated to the same level or higher than they. Lgbtq+ would be good. As an asexual I'm never really sure where I fit. Fitting somewhere would be good. Thanks for taking the time to do this research - you are appreciated! x Some answers need donâ&#x20AC;&#x2122;t know/ not applicable. There is a question on being put to sexual Health professional. I am not out to any sexual health professionals, because I have never seen a sexual health professional. I wonder whether there is a hidden assumption in this question that all LGBT will engage with the sexual health services I am really glad to see this survey. I recently conducted research in Merseyside on this topic and recently spoke nationally on the news about it. One of the main recommendations I have had was around gathering insight with local LGBT+ people to help tailor training in how to engage with the community (particularly older LGBT+ people who have even worse outcomes). Thanks for doing this!

I was at a meeting today at work (I work at a hospital), this link for this survey was given to me. I think this is a very worthwhile study and piece of work. I hadn't really considered the subtleties of health issues for our community and I'm part of it! Often 'we' don't want to be treated differently, however, there are differences in health needs and which screening programmes for example which may needed.

Thank you so much for doing this. It'll be great to feel more included at the doctors Thank you!! =)

Nope. I think it is relevant but could do with something including the usage of E-Cigs and including boxer for trans male and female to identify in gender and gender identity Survey should ask: which toilet do you use? Are you on hormone therapy? Legal or illegally prescribed, are your family supportive? Are you on antidepressants? What is your profession? What is your annual income What a massive waste of money from Macmillan to be supporting this abismal survey and project. Macmillan cancer support is for everyone regardless of gender expression or sexual behaviour. Macmillan already provides great support with their nurses and this should not be ignored or forgotten. I do not see myself as part of an "LGBT" community, although I do have LGBT friends and other friends who know my sexuality. Much research seems to focus on "communities" but these do not exist as a physical reality and many people are outside of them. Survey long overdue!

The survey assumes I am a regular attendee of a medical professional, therefore it was difficult to answer at times.

Some people also chose to use this question to share some of their personal wishes as an LGBT person, as well as some of their own experiences. Below is a selection of these responses. All are repeated as submitted. The only cancer I ever get information on (by post) from my doctors surgery is cervical cancer; I get invited to have a smear test every few years and the wording of it grosses me out because it assumes I am a cisgender woman. When I went to get screened for breast cancer a few years ago, the nurse dealing with me assumed I wore a bra (I wear a chest binder) when asking me to undress. When being asked questions over the phone by a medical professional (mental health) a few months ago, when asked about my sexuality they assumed I was heterosexual, so I had to correct them. When I see medical information on screens in waiting rooms it is always geared towards straight and cisgender people.

Cancer treatment/screening needs to acknowledge that the LGBTQ community exists. We had at length discussions about my ovaries during treatment because of my sexuality I never wanted kids and cycles were always a problem for me because of sexuality this was not acknowledged. There needs to be more LGBTQ awareness. I now feel somewhat isolated going through breast cancer treatment as my sexuality and issues I experience is not understood. When I was in Southport hospital for a non cancer related issue my husband visited me and our sexuality was quite obvious but there were no issues. I have experienced 'assumed hetersexuality' at the sexual health clinic at Liverpool Royal GUM clinic. I've not had any sexual health advice offered to me as a woman who has sex with other women. I've been offered condoms when I've been in a relationship with a woman and the staff haven't thought to ask if that was appropriate. And I've been asked about birth control when I've been in a relationship with another woman. Somehow I feel there should be more open support of LGBT people who have lost their partner I am sure that treating patients as straight is the set pattern unless the patient insists on being treated as not straight. During illness one does not always have the strength to do this. Also, part of a patient's mentality is to obey - be good - because we want to get better and so we dont rock the boat.

A lot of poor health choices often come from a poor sense of self esteem or conflict with coming to terms with sexuality. This seems to encourage choices which give short term boost, but with long term consequences i.e. riskier sexual practices, smoking, drug use, alcohol consumption. lesbian sexual health clinics, for smears, etc well being etc, pre pregnancy support,

i feel like there should be more info about how cervical cancer can affect lesbians. Does it affect lesbians, or are lesbians safe? Also, I have only ever had 1 smear - it was horrendous and has scared me off having more. I think the speculum is far too large for someone who has never had penetrative sex - surely there are a lot of lesbians in this category.

Mental health difficulties are at root of our communities higher prevalence of alcohol, drug use and sex risk taking

To give more medical information relevant to the LGBT community i.e prostate information to trans females i.e cervical screening to trans males More needs to be done locally around identifying the population who describe themselves as LGBT. Health & Care staff should receive more training on awareness of non-binary sexuality and/or sexual identity

More inclusivity for non-binary people needs to spread across the health service. Some expamples of how this could be achieved: Gender neutral title option (Mx) All reception staff trained in language awareness, and the impact of using incorrect gendered language and pronouns Change systems to allow for non-binary people to be corretly ifdentified on paperwork

The only informaton taiored to the lgb community seems to be for gay men

LGBT awareness and equality training is needed for many health care professionals, as well as an understanding of the mental and emotional effects of long term discrimination, prejudice, exclusion and hate crimes.

I also feel I do not want to be pigeon holed, I want to feel included but not where I am directed more towards say LGBT NHS worker, if anything this might make me feel more uncomfortable, posters just need to include all

I think mental health support, and positive mental health is really important and severely underfunded in the UK (for straight people too) I think changes in technology (dating apps, social networking sites etc) have really reduced isolation in LGBT people and allowed so many people to find "their tribe" and come out! Liverpool has changed so much. 5 years ago i was really nervous holding my girlfriend's hand in public, but nowadays I do it all the time without even thinking about it. more targeted information for the LGBT communities and some sessions offered by Halton GP's aimed at gay men

Interpreting the data and making recommendations Our survey data highlights numerous areas in which LGBT people in Merseyside experience significant health inequalities. We identified three areas in which targeted improvement could be made in order to reduce these inequalities. Note that as the LGBT Cancer Programme Merseyside is one focused on cancer amongst LGBT people, these recommendations focus primarily on health inequalities amongst LGBT people in relation to cancer. However, these recommendations are broad and can be applied to other longterm health conditions.

Campaigns The survey highlights a low level of knowledge of cancer across the board, but with even starker lack of knowledge for cancers that may be statistically more prevalent in LGBT communities (although more research is needed to fully understand this). From the survey and other research, we know that LGBT people both in Merseyside and nationally are much more likely to smoke than the general population. We also know that LGBT people both in Merseyside and nationally are much more likely to drink excessively than the general population. Smoking causes cancers of the lung, liver, bladder, kidney and mouth amongst others.33 Excessive alcohol use causes a disease of the liver called cirrhosis, which can increase the risk of developing liver cancer. Excessive drinking also increases the risk of developing cancer in the mouth, upper throat, larynx, oesophagus, breast and bowel.34 In spite of LGBT people being statistically more likely to engage in behaviours that cause certain types of cancer, selfdescribed knowledge of those cancers amongst LGBT people is low. A mere 7.83% of LGBT people in Merseyside have accessed information about liver cancer. 10.43% have accessed information about oral cancer(s). Only 19.13%

"How Smoking Causes Cancer", Cancer Research UK, 2016 <https://www.cancerresearchuk.org/aboutcancer/causes-of-cancer/smoking-and-cancer/how-smoking-causes-cancer> [Accessed 5 November 2018]. 34 "How Alcohol Causes Cancer", Cancer Research UK, 2016 <https://www.cancerresearchuk.org/aboutcancer/causes-of-cancer/alcohol-and-cancer/how-alcohol-causes-cancer> [Accessed 5 November 2018]. 33

have accessed information about lung cancer or bowel cancer. The lack of knowledge of those cancers may be a contributing factor to LGBT people being more likely to engage in those cancer-causing behaviours. Campaigns, and campaigning materials, to target the LGBT community aimed at addressing this low knowledge and increased propensity for certain cancer causing behaviours would reduce this inequality. This could take many forms, such as a stop smoking campaign aimed specifically at LGBT people delivered in partnership with third-sector organisations. This could also mean health resources aimed at LGBT people around lung or liver cancer. The survey, in revealing disparity between respondents, also highlighted the need for campaigns targeting different communities of identity within the LGBT community such as targeting Gay and Bisexual men around drug use or improved sexual health messaging for Lesbian and Bisexual women.

Research The survey highlights the pressing need for more research into health inequalities for LGBT people. Much of what is reflected in our data required further research to either flesh out more or attempt to find a causal factor for the inequality. The data revealed many stark health inequalities for LGBT people in Merseyside such as higher rates of smoking, drug or alcohol misuse and mental health issues. Yet this raises questions and points of inquiry that require further dedicated research. For example, we know that 1 in 3 LGBT people in Merseyside have experienced discrimination, but we do not know that the impact of that has been, or how this may be related to other inequalities. We also know little about the disparities within the LGBT community that the survey identified, such as the lower rate of disclosure and higher rate of discrimination amongst LBT females, or the higher rate of mental health issues and drinking amongst GBT males. The survey also highlighted a need for further research in order to build upon the information we now have. The response levels from some of the smaller 68

boroughs of Merseyside (Halton, Sefton etc) as well as the Trans community was lower than in the larger boroughs or in the wider LGB community respectively. This could account for some disparities in data or anomalies in response figures. A more in depth dedicated study would allow for higher response rates from those communities thus producing more thorough data. Alongside further research, fully implemented sexual orientation monitoring for patients would ensure that health inequalities for LGBT people are more easy to quantify for further research and targeted services.

Training and Resources The survey highlights a need to empower staff in medical settings and ensure they are more confident in being able to combat discrimination and meet the needs of their LGBT patients. We know from our respondents that 1 in 3 LGBT people in Merseyside have witnessed or experienced discrimination or poor treatment due to sexual orientation or gender identity. This rises to 1 in 2.5 amongst those who identify as female and 9 in 10 amongst Trans people. We know that 1 in 4 do not disclose their sexuality or gender identity to medical or sexual health professionals through fear of a negative reaction or discrimination. Training for medical professionals would empower them to meet the needs of their LGBT patients, particularly those from subsets within the community, as well as enabling LGBT people to feel comfortable disclosing their sexuality or gender identity and being able to receive the treatment they need. The survey also highlights a need for resources specifically tailored towards LGBT patients. In every borough of Merseyside, no more than half of respondents could recall seeing any posters or resources aimed at LGBT people. We know that only 34% of LGBT people have accessed information that is relevant to their sexuality or gender identity, whilst nearly half have been given information that is not relevant to them due to their sexuality or gender identity. The development of resources tailored towards the LGBT community would help reduce the inequality they face when accessing support thus improving overall outcomes. 75% of respondents indicated that they felt they 69

would benefit from resources tailored to the LGBT community, whilst 81% felt that they knew someone who would benefit. With training on meeting the needs of LGBT patients given as standard, as well as resources aimed at LGBT people, this would help to create LGBT affirmative clinical spaces, which has been shown to improve outcomes for LGBT people.

References Action on Smoking and Health (ASH), Smoking And The LGBT Community (London: ASH, 2016) "Breast Screening: Programme Overview", GOV.UK, 2015 <https://www.gov.uk/guidance/breast-screening-programme-overview> [Accessed 5 November 2018] Brighton and Hove LGBT Switchboard, LGBTQ People Affected By Cancer Report (Brighton: Macmillan Cancer Support, 2018) British Heart Foundation, Physical Activity Statistics 2015 (Oxford: British Heart Foundation Centre on Population Approaches for Non-Communicable Disease Prevention. Nuffield Department of Population Health, 2015) "Can Trans Women Get Prostate Cancer?", Prostate Cancer UK, 2018 <https://prostatecanceruk.org/prostate-information/are-you-at-risk/trans-women-andprostate-cancer> [Accessed 5 November 2018] "Cervical Screening: Programme Overview", GOV.UK, 2015 <https://www.gov.uk/guidance/cervical-screening-programme-overview> [Accessed 5 November 2018] Doderer, Yvonne, "Lgbtqs In The City, Queering Urban Space", International Journal Of Urban And Regional Research, 35 (2011), 431-436 Fish, Julie, and Ruth Hunt, Prescription For Change: Lesbian And Bisexual Womenâ&#x20AC;&#x2122;S Health Check (London: Stonewall, 2008) Fish, Julie, I Williamson, Jayne Brown, Wendy Padley, Kathleen Bell, and J Long, Promoting Good Outcomes In Lesbian, Gay And Bisexual Cancer Care: A Qualitative Study Of Patientsâ&#x20AC;&#x2122;Experiences In Clinical Oncology (Leicester: DeMontfort University, 2018) Government Equalities Office, National LGBT Survey: Research Report (London: HM Government, 2018) Home Office, Drug Misuse: Findings From The 2016/17 Crime Survey For England And Wales(London: HM Government, 2017) "How Alcohol Causes Cancer", Cancer Research UK, 2016 <https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/alcohol-andcancer/how-alcohol-causes-cancer> [Accessed 5 November 2018] "How Smoking Causes Cancer", Cancer Research UK, 2016 <https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/smoking-andcancer/how-smoking-causes-cancer> [Accessed 5 November 2018] "Liverpool City Region Demographic Information", Merseytravel.Gov.Uk, 2018 <https://www.merseytravel.gov.uk/about-us/corporate-information/corporate-

responsibility/Documents/Liverpool%20City%20Region%20Demographic%20Information %20March%2017.pdf> [Accessed 5 November 2018] Macmillan Cancer Support, The Emerging Picture On LGBT People With Cancer (London: Macmillan, 2013) Marwaha, Steven, Nick Parsons, Sarah Flanagan, and Matthew Broome, "The Prevalence And Clinical Associations Of Mood Instability In Adults Living In England: Results From The Adult Psychiatric Morbidity Survey 2007", Psychiatry Research, 205 (2013), 262-268 NHS England, Breast Screening Programme, England - 2016-17, PAS (London: National Health Service, 2018) "PHE Concern As Cervical Cancer Screening Uptake Continues Decline", Pulse Today, 2018 <http://www.pulsetoday.co.uk/clinical/clinical-specialties/cancer/phe-concern-as-cervicalcancer-screening-uptake-continues-decline/20035618.article> [Accessed 5 November 2018] "Prostate Facts For Gay And Bisexual Men", Prostate Cancer UK, 2018 <https://prostatecanceruk.org/prostate-information/living-with-prostate-cancer/gay-andbisexual-men> [Accessed 5 November 2018] Stonewall, Gay And Bisexual Menâ&#x20AC;&#x2122;S Health Survey 2012 (London: Stonewall, 2012)

Appendix A â&#x20AC;&#x201C; Blank Questionnaire

Appendix B â&#x20AC;&#x201C; Full Answers to Q16

Heteronormative behaviour and visible uncomfortableness Assumption that I am in a heterosexual relationship. Ignoring questions and concerns relating to my sexuality. I have experienced different treatment and micro-agressions Was told that my asexuality wasn't valid. Asked if I was abused as a child. Being LGBT I wasn't offered a biscuit after blood donation Several times I have been told if I decide to be with a man I need to tell me doctor of change of circumstances. Another time I was told when I stop being with my 7 and a half year partner to go on contraception. mainly that a request for cialis will be denied as sex for gay people is recreational and not part of a loving relationship: find one and then I will be given the cialis. Also basically when being addressed in a group - I attend cardiac rehab groups - it is assumed we all have wives and children - and refer to to them in the style of 70's Brit TV sitcoms Homophobia I heard nurses in the royal talking about. A fucking fag I’m the waiting room My female partner and i regulalry experience indirect homophobia when we attend the Hewitt centre at Liverpool Womens Hospital for IVF Treatment. We've been patients at the clinic for four years. Yes, but this was 20 years ago with a particular GP. I changed practice. No issues since with any health professionals. overheard dr at women's hospital talking about my appearance I was ejected from a blood donation van due to identifing as being gay, depote being a virgin who had not even been kissed at that time. I was 17 and it deeply affected me. I went for a full STI MOT with my partner to the GUM cliic when we decided to be monogamous with each other at the royal in Liverpool. I was treated with suspiscion as they could not believe I was doing this without having had a scare and was just vbeing responsibily proactive. I was even consoled by the healthcare practitioner that I "didnt have to go through with sex if I was vbeing pressured into it" as my partner is 10 years older and she thougth I was being coerced in some way. I dont feel this would have happened to a heterosexual couple. I am a public health professional who constantly faces normalised discussion around the health risks associates with men who have sex with men but never have I ehard anyone discuss how heterosexual people engage with anal sex or anallingus. Poor customer service I was told I should be hanging from a tree, by HCA, when I was a Staff Nurse at Charing Cross Hospital Assumptions made by counsellor that I was heterosexual and then assumptions made that issues were related to sexual orientation Had 3 GPs refuse my request to Leeds gender clinic and for counselling. Inappropriate questions from nurse in hospital about which genitals I have. Only through second hand comments 8 years ago my wife and I were refused fertility treatment by our CCG, we were told that only hetro couples could get funding. Heterosexual presumption in smear test Not being given the right information, heteronormative assumptions, visible discomfort from doctors when discussing it People being laughed at/not offered certain female cancer checks Clatterbridge pain clinic Asked to do pregnancy test - even though stated sexuality a few times & doctor was homophobic In my country of origin My partner with a pain clinic I don’t know if this counts but the school nurse told me that I wasn’t trans. I think she said that because of a family member of mine. A trans woman being misgendered as a male (even though she was passing rather well) at hospital. They called her Mr, and used her birth name instead of her preferred name. Forced pregnancy test on lesbian female before allowing any pain relief to be administered in A&E resulting in a wait of 5 hours before any pain relief given. The GP was uncomfortable and was only able to refer me to the Psychosexual Health service, which wasn't really what I needed. Had my GP laugh in my face repeatedly, tell me I was stupid, laughed some more then flat out refused when I asked for blood tests well taking hormones DIY. wouldnt prescibe me skin medication for risk of getting pregnant depite being in a long term relationship with a woman

As a nurse I have witnessed discrimination against patients due to their sexuality Treated as a male by a nurse during a hospital admission. They assume I am promiscuous and have talked to me in a derogatory and judgemental manner, although I am an ex health professional and fully understand how to protect myself and my sexual health hospital staff discrininating against people with HIV Lack of privacy. Rudeness around sexuality during pre-HIV test consultation Witnessed discrimination against people living with HIV/AIDS - context relates to previosu employment 25-30 years ago. Issues related to discriminatory language, stereotyping, stigmatisation, etc. years ago About 8-9 years ago i had a rather unpleasant awkward response from my older male Muslim GP when i mentioned my girlfriend Unwillingness from a nurse to discuss if I needed a cervical smear as I had never had a heterosexual relationship. I made it clear that I was a lesbian but she failed to acknowledge this. She told me to come back when I was "ready for a relationship". This was many years ago. Also a few years back a doctor at the Women's Hospital (I attended as an emergency following complications from an op) asked me about sexual health but made the presumption I was heterosexual - seemed embarrassed when I told her my sexuality. Many years ago in London - discrimination and negative comments about my sexuality when declining contraception from a nurse Repeatedly being asked if I could be pregnant. Confusion about whether or not I needed to have cervical smear tests. Nothing major just asumptions based on my gender when going for smears or gynae matter- Hetronormative treatment

Appendix C â&#x20AC;&#x201C; Full Answers to Q18

A lot of cancer treatment is generic it was easier to go along with what was on offer as opposed to what I needed regarding my sexuality I was not out at the time. Because of fear of being made an issue when it was not relevant to my diagnosis Just wasn't sure how it would be taken and didn't think it was relevant to the issue They made the assumption i had a girlfriend and I felt too awkard to correct them. fear of judgement Stigma. Fear Scared of what they would have thought about me Some time ago now but was concerned about negative reactions. So not to be judged about my sexuality There was a slight language barrier but mainly because I was unsure of the cultural opinion from the consultant. It felt easier/safer to avoid the specifics of my sexuality - noted as married, it was assumed I am married to a man. Anxiety over being judged was worried about not getting the correct procedure Ignorance Giving Blood as an idiotic way of seeing if I might be HIV+ when I was 20 Attitude of medical professional I experienced domestic abuse by my (ex)wife. I was having a lot of 'accidents' and my mental health was suffering. I was never asked about my injuries by either my GP or at A&E. This went on for over 10 years. I also didn't offer the information as often my (ex) wife would be with me and domestic abuse screening was not offered to me. I didn't tell my gp until after the relationship had ended and I needed help with my mental health. Actually, I ended up self-referring into IAPT and was diagnosed with PTSD. I got a lot of help from the therapist I was seeing, he was fantastic and I felt I could be totally open with him, so this isn't one sided- I;m not against health professionals, I just don't think they are as aware of the prevalence of domestic abuse in same-sex or inter-sex relationships. Fear of being treated differently, looked down upon I've attended therapy on numerous occasions and never told any therapist that I identify as LGBT although it is a massive part of my life and always dance around the topic and any speak of my relationships I didn't know what reaction I'd get, I just said partner instead of boyfriend I couldn't see what positive effect it could have Because of discrimination in my country of origin I do not feel comfortable coming out in the UK I was uncomfortable going to my GP about my gender identity and went private with therapy to start It was a scary decision to make, it was one that I did not want to take. Transphobic GP Concern over being judged Assumption made that I was straight, felt too awkward to correct, thought it would be easier to just go along with it I just didn't want the rolled eyes. I just wanted a full STI check without the patronising 'lesson' on sexual health I was unconfortable with the persons probing me for every detail where as my GP I can talk to and be relaxed about everything I have to say Some GPs and health professionals i just decide i don't need to mention my girlfriend I was younger and less confident Concerns would receive sub standard treatment or would be judged their attitude

Appendix D â&#x20AC;&#x201C; Full Answers to Q32

LGBT community more image and health conscious I don't really think smoking is anything to do with LGBT Don't know It seems to be part of the culture - particularly those who are regularly on the 'scene', it is seen as the thing to do - grab a drink, head out for a cigarette and a chat. Also most bars have the music too loud to chat, so the only place to chat is in the smoking area. I know many 'social' smokers, who only smoke at bars. I'm not sure why Image, peer groups unsure Lot of the scene based around bars and clubs It seems a trait with LGBT people Different ratio or proportion of people in either community. Fashionable We are encouraged to use clubs and bars as places to meet and self-identify: you are more likely to drink and/or smoke in such places so therefore... I feel like I see more people standing outside straight pubs smoking than I do gay pubs There was no box for not sure so I selected more. Lifestyle more oriented around specialising and alcohol Health education in the LGBT community seems to poorer than in the general population. The wider determinants of health - statistically LGBT+ people have worse health behaviors and outcomes when compared to their heterosexual counterparts. This is likely due to the heteronormative discourse at a societal level disproportionately discriminating against sexual minority groups in both direct and indirect ways. LGBT people seem to have more addictive personalities. Addiction can be preverlant in LGBTQ community It seems to be more acceptable in the community Social aspect and image learned peer behaviour Seems to be part of the pub culture on the gay secene Due to lifestyle Less motivation to stay well due to internalised homophobia and impact of homophobia Stress oppression coping Less healthy choices coupled to lower income, lower self esteem and social isolation Seen as trendy, more normalised in LGBT culture Anxiety maybe No idea I'm not sure, but I don't think I've ever seen someone I know is in the LGBT+ community smoking a cigarette. I think a lot of LGBT-specific social events are often oriented towards drinking & partying, so opportunities to spend time with other queer people as queer people take places where there are people who smoke, which makes smoking a more social activity & harder to completely quit. I think anxiety and mental health also has something to do with it. Social and cultural. The majority of social venues that are specifically for LGBT people are bars and clubs therefore there is an increased prevalence of alcohol use and a lot more of them will smoke whilst they drink. stress related, lots of anxious members of the community Poorer mental health among LGBT community usually results in higher rates of risky behaviours Peer pressure and stress. Stigma and anxiety leading to coping strategies Historical lifestyle eg: no children, hedonistic lifestyle More stress, more focus on bars, LGBT people less likely to have kids so less likely to "settle down" and be healthy

Nerves or fitting in. it seems that all gay men smoke Anxiety. Weight control.

Appendix E â&#x20AC;&#x201C; Full Answers to Q36

Because non-LGBT people have issues too More hedonistic society, with currently a lesser chance of children requiring looking after - lets face it, accidental pregnancies are not really a concern in the gay community. Alot of the culture surrounds going out to meet people in pubs/clubs Gay communities revolve around socialising, socialising is drinking Mental health issues, discrimination. People self medicate Lot of the scene based around bars and clubs LGBT people enjoy it socially The lifestyle is confusing to high risk taking behaviour. Including high risk sexual behaviour The LGBT community tend to go out more socially and enjoy socialising in clubs see previous answer more prevalent in social scene although I am not part of that Gay pubs are where we hang out and meet up so drink is more readily available LGBT Community is more social Generally the LGBT have less family ties and their lifestyles mean that social drinking more regularly is commonplace. I do not socialise in queer spaces but I used to and this is why I do not anymore. Loneliness, and maybe having some problems Most of the venues for the LGBT Community to gather are pubs/clubs. There really isn't anywhere else! Social is more important As before Mental health issues Due to gay and lesbian bars being a more welcoming place and therefore more likely to drink when in this environment. Mix this with the potential for issues surrounding sexuality making life difficult to cope with, alcohol can become a crutch to help. Higher than average alcohol consumption is more prevalent in the LGBT community because its part of the culture and there is a higher prevalence of mental health issues. See previous response re smoking Alcohol can combat shyness. Inhibitions get lost and confidence can grow after a few drinks. Due to the social settings that LGBT people meet in. Gay scene is around alcohol Used as a way to socialise with people. Ease nerves. Makes it feel easier to hook up with someone. Party lifestyle. Social isolation. People going out to try and meet people/date as dating apps have an impact on peoples expectations of sexual relationships If you drink excessive then your drinking to forget who you are. learned peer behaviour pubs are a major part of the gay community -getting drunk is part of the macho imagne probably only in the younger generations. a lot of lgbt life is centred around bars and clubs. I think it is heavily used, especially on 'the scene' Due to lifestyle Stress oppression loneliness limited social outlets Lower levels of mental well-being, greater financial uncertainty, social isolation, internalised negativity leading to selfdestructive behaviour Due to rising rents, most LGBT spaces are now bars or clubs. There are few places you can mix with other LGBT people that don't involve alcohol. Most LGBT meetings places are night clubs Used as a coping strategy. Drugs and alcohol is normalized in the community. It's a social thing + more problems

No idea The only places it's normal to meet other LGBT+ people without needing to do the awkward "oh my god you're amazing and cool but I don't know if you're attracted to people of my gender or not" (which you have to go a long time without knowing so that it doesn't sound creepy when you ask, may I add) is at gay bars. Yknow, where alcohol is served. We need some gay cafĂŠs and restaurants and such so that the under 18s can find others like them without having to be out to everyone to do so. As before, a lot of LGBT social activities take place in bars, clubs, pubs and it can be difficult to avoid alcohol when trying to meet/spend time with other LGBT people. Again, I think mental health also has an impact, stress and anxiety relief, also think there are a lot of 'damaged' people in this community Poorer mental health One of the ways I used to drown out dysphoria, some of my other trans friends used alcohol or other drugs in the same way. The social settings in which LGBT people find each other are often venues that sell alcohol Peer pressure and stress. As above Social habits. Stress/stigma means some people use it to self medicate A lot of LGBT social life is focused around bars/clubs LGBT people are less likely to have kids so don't tend to settle down and will keep going out/drinking Mental health The lifestyle promotes this, less likely to be tied down with Children. I have read research indicating it is more prevalent. I don't know why it would be the case Their is a culture in the gay community of the scene being bars and clubs

Appendix F â&#x20AC;&#x201C; Full Answers to Q41

A tan is perceived as sign of health + wellbeing, media influence Body image, previous body shame/self resentment Fashionable wanting to look good We are encouraged to think of beautification as part of our self identity - and also just spend money. Gayness - and but to a far lesser extent LB and T - is as much economic term as a social one - you are gay not when you have sex with the same sex - that is being homosexual - but when you spend money to self-identify as doing so. vanity Certainly among younger gay men, there does seem to be a prevalence in sunbed use. Gay men are attracted visuals. If you look your best, you are more likely to attract potential partners. Increased body image. Need to fit gay stereotype I do see younger people on the gay scene who clear have used a sunbed (and tanning products) A trend in Liverpool, mainly amongst gay men It tends to be most prevalent for straight women More prevalent with gay/bi males I think more gay men use the sunbed than straight men Perception by some gay men is tanned skin equals beauty and healthiness Image. Image Possibly higher in gay men but lower in lesbians? Thats just a guess though. Some of this may be because of pressure on younger gay men to look a certain way. Historicallu young lesbians haven't had the same pressure but i suspect this is changing Image The seems to be a culture of this in liverpool

100

Appendix G â&#x20AC;&#x201C; Full Answers to Q42

101

No it's ok. The survey is right. Information on HIV pre drugs hard to find The only cancer I ever get information on (by post) from my doctors surgery is cervical cancer; I get invited to have a smear test every few years and the wording of it grosses me out because it assumes I am a cisgender woman. When I went to get screened for breast cancer a few years ago, the nurse dealing with me assumed I wore a bra (I wear a chest binder) when asking me to undress. When being asked questions over the phone by a medical professional (mental health) a few months ago, when asked about my sexuality they assumed I was heterosexual, so I had to correct them. When I see medical information on screens in waiting rooms it is always geared towards straight and cisgender people. Cancer treatment/screening needs to acknowledge that the LGBTQ community exists. We had at length discussions about my ovaries during treatment because of my sexuality I never wanted kids and cycles were always a problem for me because of sexuality this was not acknowledged. There needs to be more LGBTQ awareness. I now feel somewhat isolated going through breast cancer treatment as my sexuality and issues I experience is not understood. When I was in Southport hospital for a non cancer related issue my husband visited me and our sexuality was quite obvious but there were no issues. I have experienced 'assumed hetersexuality' at the sexual health clinic at Liverpool Royal GUM clinic. I've not had any sexual health advice offered to me as a woman who has sex with other women. I've been offered condoms when I've been in a relationship with a woman and the staff haven't thought to ask if that was appropriate. And I've been asked about birth control when I've been in a relationship with another woman. Not clear why questions of class were not included in this survey. These issues are relevant to the LGBTQI community. I have been treated better than fellow LGBTQI people because I am perceived by the medical profession as middle class and educated to the same level or higher than they. Lgbtq+ would be good. As an asexual I'm never really sure where I fit. Fitting somewhere would be good. The survey assumes I am a regular attendee of a medical professional, therefore it was difficult to answer at times. Somehow I feel there should be more open support of LGBT people who have lost their partner What a massive waste of money from Macmillan to be supporting this abismal survey and project. Macmillan cancer support is for everyone regardless of gender expression or sexual behaviour. Macmillan already provides great support with their nurses and this should not be ignored or forgotten. I am sure that treating patients as straight is the set pattern unless the patient insists on being treated as not straight. During illness one does not always have the strength to do this. Also, part of a patient's mentality is to obey - be good because we want to get better and so we dont rock the boat. The non-prescription drug use is rare, just a few times a year. I'm getting on now, can't party like I used to! N/A Thanks for taking the time to do this research - you are appreciated! x Some answers need donâ&#x20AC;&#x2122;t know/ not applicable. There is a question on being put to sexual Health professional. I am not out to any sexual health professionals, because I have never seen a sexual health professional. I wonder whether there is a hidden assumption in this question that all LGBT will engage with the sexual health services No A lot of poor health choices often come from a poor sense of self esteem or conflict with coming to terms with sexuality. This seems to encourage choices which give short term boost, but with long term consequences i.e. riskier sexual practices, smoking, drug use, alcohol consumption. I am really glad to see this survey. I recently conducted research in Merseyside on this topic and recently spoke nationally on the news about it. One of the main recommendations I have had was around gathering insight with local LGBT+ people to help tailor training in how to engage with the community (particularly older LGBT+ people who have even worse outcomes). Thanks for doing this! lesbian sexual health clinics, for smears, etc well being etc, pre pregnancy support, Please have screening times that are outside of working hours! i feel like there should be more info about how cervical cancer can affect lesbians. Does it affect lesbians, or are lesbians safe? Also, I have only ever had 1 smear - it was horrendous and has scared me off having more. I think the speculum is far too large for someone who has never had penetrative sex - surely there are a lot of lesbians in this category. No thanks I was at a meeting today at work (I work at a hospital), this link for this survey was given to me. I think this is a very worthwhile study and piece of work. I hadn't really considered the subtleties of health issues for our community and I'm part of it! Often 'we' don't want to be treated differently, however, there are differences in health needs and which screening programmes for example which may needed. Mental health difficulties are at root of our communities higher prevalence of alcohol, drug use and sex risk taking Thank you so much for doing this. It'll be great to feel more included at the doctors

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There are alot of parts in the NHS that don't think about trans people when putting out forms e.g. 1 gender male female. I personally think there should be an option to state trans or non binary for those like me who are willing to have that option on a form. This would be great! Thank you Thank you!! =) I think younger women should be offered cervical screening at a younger age No To give more medical information relevant to the LGBT community i.e prostate information to trans females i.e cervical screening to trans males I wonder if LGBT people struggle with more mental health problems Nope. I think it is relevant but could do with something including the usage of E-Cigs and including boxer for trans male and female to identify in gender and gender identity Nope. Just a lot of stuff I didnâ&#x20AC;&#x2122;t understand. LGBTQ+ people are the exact same as straight or cisgender people. Just with a little extra something special. More needs to be done locally around identifying the population who describe themselves as LGBT. Health & Care staff should receive more training on awareness of non-binary sexuality and/or sexual identity The NHS Trans Support Service that operates in Liverpool is a fantastic service that needs to be better funded and expanded. This service stepped in and provided help and access to endocrinologists and voice therapy when my own GP just laughed in my face. It is not hyperbole to say that there are people alive today thanks to this one clinic, I'm still some 14 months away from my first appointment at a GIC and waiting lists for those are now counted in years, and even then you may not receive any actual help until 9 months after your first visit thanks to significant gatekeeping and old fashioned beliefs that dominate trans health care, unlike the TSS which feels utterly modern in their approach. No More inclusivity for non-binary people needs to spread across the health service. Some expamples of how this could be achieved: Gender neutral title option (Mx) All reception staff trained in language awareness, and the impact of using incorrect gendered language and pronouns Change systems to allow for non-binary people to be corretly ifdentified on paperwork I think that swingers should be added to this survey. Many swingers feel that what they do isn't just a lifestyle, it's an identity and their sexuality. They are an at risk group, many of whom are within the LGBT community, but many are straight, but have multiple partners. more targeted information for the LGBT communities and some sessions offered by Halton GP's aimed at gay men None Survey long overdue! Survey should ask: which toilet do you use? Are you on hormone therapy? Legal or illegally prescribed, are your family supportive? Are you on antidepressants? What is your profession? What is your annual income I think mental health support, and positive mental health is really important and severely underfunded in the UK (for straight people too)

I think changes in technology (dating apps, social networking sites etc) have really reduced isolation in LGBT people and allowed so many people to find "their tribe" and come out!

Liverpool has changed so much. 5 years ago i was really nervous holding my girlfriend's hand in public, but nowadays I do it all the time without even thinking about it. I also feel I do not want to be pigeon holed, I want to feel included but not where I am directed more towards say LGBT NHS worker, if anything this might make me feel more uncomfortable, posters just need to include all I do not see myself as part of an "LGBT" community, although I do have LGBT friends and other friends who know my sexuality. Much research seems to focus on "communities" but these do not exist as a physical reality and many people are outside of them. LGBT awareness and equality training is needed for many health care professionals, as well as an understanding of the mental and emotional effects of long term discrimination, prejudice, exclusion and hate crimes. The only informaton taiored to the lgb community seems to be for gay men

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