Prevalence of alcohol use amongst sexual and gender minority (LGBTQ+) communities in the UK: a systematic scoping review.

BACKGROUND: globally, alcohol use rates vary by sexual orientation and gender identity (SOGI), but UK government statistics on alcohol use in the LGBTQ+ population are missing. AIM: this systematic scoping review determined the prevalence of alcohol use amongst gender and sexual minority people in the UK. METHODS: empirical UK studies from 2010 onwards reporting the prevalence of alcohol use in SOGI compared with heterosexual/cisgender people were included. Searches in MEDLINE, Embase, Web of Science, PsycINFO, CINAHL, Cochrane Library, Google Scholar, Google, charity websites and systematic reviews were conducted in October 2021, using SOGI, alcohol and prevalence terms. Citation checking was done by two authors, with disagreements resolved through discussion. Data extraction was done by one author (CM) and checked by another (LZ). Quality assessment was performed by study design, sample type and statistical analysis of results. A narrative synthesis was qualitatively combined with a tabular presentation of results. RESULTS: database and website searches found 6607 potentially relevant citations, and 505 full texts were reviewed with 20 studies included, found in 21 publications and grey literature reports. Most were on sexual orientation, including 12 from large cohort studies. Harmful alcohol use is higher in LGBTQ+ people than heterosexual people in the UK, a result similar to that found in other countries. Qualitative data reflected alcohol's role as emotional support. Fewer asexual people drank alcohol compared with allosexual people, and there were no data available regarding intersex people. CONCLUSION: funded cohort studies and service providers should routinely collect SOGI data. Standardized reporting of SOGI and alcohol use would improve comparability across studies.

A psychosocial exploration of resistances to service user involvement in United Kingdom National Health Service (NHS) mental health services.

Policy promotes the active participation of those with lived experience of mental health difficulties in UK NHS mental health services, from the level of collaborative care-planning to service delivery, leadership and development. However, research indicates different forms of resistance to the implementation of such service user involvement. This article reports the findings of a qualitative, interview-based study which used Foucauldian discourse analysis and psychoanalytic theory to understand how resistances are produced through the interplay of clinical mental health professionals' subjectivity and their organisational context. Service user involvement was found to highlight conflicts within clinicians' roles. Central to this conflict was an ambivalent relationship to the power associated with these roles. Power could protect professionals from work related stresses, but could also be used to dominate, silence and coerce service users in ways that conflicted with the core function of providing care. Whilst important, raising awareness of such conflict will arouse discomfort and resistance where psychological defences are challenged. A parallel is drawn with psychotherapeutic change, in which resistance must be understood and worked with as part of meaningful change.

Theorising health equity research for people with intersex variance through new materialism.

Health inequalities impact sex-variant people in highly differentiated ways. This is evidenced in much academic and activist intersex research documenting the highly specific forms of inequalities arising from misrecognition, discrimination and human rights abuses inherent to pathologised accounts of non-normative bodies. Important theoretical work further interrogates the implications of sex variant subjectivities, identities and bodies for static or binary notions of both sex and gender. In this paper, we aim to contribute further to this scholarship. We draw upon feminist materialist and Deleuzean-informed understandings of materials or matter to rethink debates over sex-variant subjectivities, identities and bodies in relation to inequalities in health. We argue 'the turn to matter' and associated new materialist theories draw attention to the complex, dynamic relational assemblages and entanglements mutually constituting the affective, embodied and socio-material worlds of intersex people. Informed by these theories, we propose that inequalities can be more fully addressed through a new health equity research agenda that is co-produced with sex-variant people. This agenda will enable a fuller exploration of the unsettling but transformative capacities of intersex matters and meanings with the contextually specific understandings of equity in relation to health and health care.

Barriers in care pathways and unmet mental health needs in LGBTIQ + communities.

Lesbian, gay, bisexual, transgender, intersex, queer people and minority gender identities and sexualities (LGBTIQ+) are often stigmatized and experience discrimination in health care settings, leading to poorer mental health outcomes and unmet needs compared to heterosexual and cisgendered peers. It is thus imperative that mental health providers consider and address structural challenges in order to reduce mental health inequalities of this population. This narrative review assessed the barriers that may prevent access to care and the pathways for care in LGBTIQ + communities. PubMed, PsycInfo, Embase, and Scopus were searched for papers published between December 2021 and February 2022. A total of 107 papers were included with studies reflecting five themes: (1) Unmet mental health needs; (2) Young people; (3) Substance abuse and addiction; (4) Barriers and pathways to care; and (5) Interventions. Findings demonstrate that LGBTIQ + people experience stigmatization and higher rates of substance misuse and mental ill health, which may lead to barriers in accessing health care services, and fewer tailored interventions being provided. These findings have implications for policy, health care screening, and how specialist services are structured. Substantial gaps in the evidence-base exist, and future research should examine how mental health care providers can challenge social issues that maintain discriminatory and stigmatizing practices, and support LGBTIQ + individuals to sustain their resilience.

More 'milk' than 'psychology or tablets': Mental health professionals' perspectives on the value of peer support workers.

BACKGROUND: Though growing numbers of peer support workers are employed in the UK National Health Service (NHS), conflicts persist between core values of peer support and values which exert power within these services. OBJECTIVES: To explore what NHS mental health professionals value about the peer support worker role. DESIGN: Five professionals from different professions and mental health settings were interviewed twice. The first interviews explored their experiences of working with peers. Transcripts were analysed using discourse analysis and psychosocial theory. Second interviews allowed participants to respond to the analysis and influence subsequent analysis. RESULTS: Mental health professionals valued peers for the deeply empathic, relational approach they brought, based in their subjective experience. Peer work was also valued for the affect-focused quality of this work, and the challenge peers pose to existing values in mental health services. The values of peer support troubled dominant ways of working based in forms of knowledge that favour objectivity and hence encountered challenges. CONCLUSIONS: Peers fulfil the role of amplifying the status of diverse forms of knowledge, values and related ways of working that have become marginalized in NHS mental health services. It is important that peers are not seen as an isolated solution to the marginalization of these forms of knowledge and values, but that their way of working becomes reflected in other roles whilst evoking change throughout these services. PATIENT OR PUBLIC CONTRIBUTION: Patient and Public Involvement groups were consulted both in the design and analysis stages of the study.

A Systematic Review of the Health and Healthcare Inequalities for People with Intersex Variance.

Extensive research documents the health inequalities LGBTI people experience, however far less is known for people with intersex variation. This paper presents a review of intersex health and healthcare inequalities by evaluating research published from 2012 to 2019. In total 9181 citations were identified with 74 records screened of which 16 were included. A synthesis of results spans nine quantitative, five qualitative and two narrative reviews. Literature was searched in Medline, Web of Science, Cochrane, PsychINFO and CINAHL. People with intersex variance experience a higher incidence of anxiety, depression and psychological distress compared to the general population linked to stigma and discrimination. Progressive healthcare treatment, including support to question normative binaries of sex and gender, aids understand of somatic intersex variance and non-binary gender identity, especially when invasive treatment options are avoided or delayed until individuals are able to self-identify or provide consent to treatment. Findings support rethinking sex and gender to reflect greater diversity within a more nuanced sex-gender spectrum, although gaps in research remain around the general health profile and the healthcare experiences of people with intersex variance. More large-scale research is needed, co-produced with peers who have lived experience of intersex variation to ensure policy, education and healthcare advances with greater inclusivity and ethical accountability.

Healthcare professionals' assumptions as barriers to LGBTI healthcare.

Lesbian, gay, bisexual, trans and intersex (LGBTI) people experience significant healthcare inequalities and barriers to healthcare services. Contextualised within six Member States of the European Union (EU), this paper discusses efforts to identify and explore the nature of barriers to healthcare as part of Health4LGBTI, a 2-year pilot project funded by the EU. Data were generated through focus groups and interviews with LGBTI people and healthcare professionals and analysed using thematic analysis. Findings reveal that barriers to healthcare are underpinned by two related assumptions held by healthcare professionals: first, the assumption that patients are heterosexual, cisgender and non-intersex by default; second, the assumption that LGBTI people do not experience significant problems (and therefore that their experience is mostly irrelevant to healthcare). On the other hand, it is notable that responding healthcare professionals were broadly 'LGBTI-friendly'. Thus, we argue that efforts to improve LGBTI healthcare should not be limited to engaging with healthcare professionals with negative views of LGBTI people. Rather, such efforts should also tackle these assumptions amongst LGBTI-friendly healthcare professionals.

Exploring young people's emotional well-being and resilience in educational contexts: A resilient space?

The term 'resilience' is pervasive in narratives of young people's emotional well-being. However, the meaning it has for those it describes is perhaps less well understood. Resilience was investigated as part of an engagement exercise into health improvement commissioning in educational contexts in the South East of England. One hundred and nine young people in total were involved, and this article reports data collected from two areas that were explored, comprising a sub-set of 58 participants: emotional well-being and resilience (n = 23) and the whole school approach (n = 35). It was apparent that while not all participants engaged with the term 'resilience' itself, they nevertheless often adopted creative individual and collective strategies to protect and enhance their emotional well-being. Furthermore, participants reported a sense of resilience that arose from a shared sense of adversity that helped strengthen collective support and solidarity, thus supporting previous work on emergent collective resilience. Theoretical and practical implications are discussed, along with a recommendation for more participatory research, so that young people can be more confident that their views are being considered within such exercises.

Training healthcare professionals in LGBTI cultural competencies: Exploratory findings from the Health4LGBTI pilot project.

OBJECTIVES: Lesbian, gay, bisexual, trans and intersex (LGBTI) people experience health inequalities and barriers to accessing healthcare at a greater rate than the general population. This paper aims to present the Health4LGBTI training course for healthcare workers and the results of its pilot implementation. METHODS: Funded by the European Parliament, the training course was developed by a multidisciplinary team including LGBTI organisations as part of the Health4LGBTI Project. 110 healthcare professionals from diverse medical fields attended the pilot training in six European Member States. Knowledge and attitudes were compared on the basis of a pre-post evaluation design utilising an ad hoc questionnaire. RESULTS: Knowledge scores increased after the training, irrespective of age and sexual orientation of participants. Attitudes scores generally improved, particularly in terms of inclusivity and a greater acknowledgement of LGBTI health needs and self-competence. CONCLUSION: The Health4LGBTI training course is both feasible and effective in training healthcare professionals and support staff to improve cultural competence and thereby promoting inclusive healthcare practice. PRACTICE IMPLICATIONS: The Health4LGBTI training course can be implemented in different healthcare contexts. Piloting of the course provided an opportunity for healthcare professionals and for support staff to improve their knowledge of, and attitudes towards, LGBTI people.

Co-producing knowledge of lesbian, gay, bisexual, trans and intersex (LGBTI) health-care inequalities via rapid reviews of grey literature in 27 EU Member States.

BACKGROUND: The health inequalities experienced by lesbian, gay, bisexual, trans and intersex (LGBTI) people are well documented with several reviews of global research summarizing key inequalities. These reviews also show how the health-care needs of LGBTI people are often poorly understood whilst suggesting that targeted initiatives to reduce inequalities should involve LGBTI people. OBJECTIVES: To determine what is known about the health-care inequalities faced by LGBTI people? What are the barriers faced by LGBTI people whilst accessing health care, and health professionals when providing care? What examples of promising practice exist? DESIGN: Rapid reviews of grey literature were co-produced with LGBTI people in 27 countries followed by a thematic analysis and synthesis across all data sets. The review included grey literature from each country that might not otherwise be accessible due to language barriers. MAIN RESULTS: Rapid reviews showed that LGBTI people faced various inequalities and barriers whilst accessing health care. Where heterosexuality, binary gender and assumed male/female sex characteristics were upheld as the norm, and where LGBTI people differed from these norms, discrimination could result. In consultations where LGBTI people feared discrimination and did not disclose their LGBTI status, health professionals lacked the information required for appropriate assessments. CONCLUSION: With greater understanding of sexual orientation (LGB people), gender identity (trans people) and sex characteristics (intersex people), combined with access to contemporary knowledge and training, health professionals can work in collaboration with researchers, policymakers and LGBTI people to develop systems that are better attuned to the needs of all service users.

A review of lesbian, gay, bisexual, trans and intersex (LGBTI) health and healthcare inequalities.

BACKGROUND: Lesbian, gay, bisexual, trans and intersex (LGBTI) people experience significant health inequalities. Located within a European Commission funded pilot project, this paper presents a review of the health inequalities faced by LGBTI people and the barriers health professionals encounter when providing care. METHODS: A narrative synthesis of 57 papers including systematic reviews, narrative reviews, meta-analyses and primary research. Literature was searched in Cochrane, Campbell Collaboration, Web of Science, CINAHL, PsychINFO and Medline. The review was undertaken to promote understanding of the causes and range of inequalities, as well as how to reduce inequalities. RESULTS: LGBTI people are more likely to experience health inequalities due to heteronormativity or heterosexism, minority stress, experiences of victimization and discrimination, compounded by stigma. Inequalities pertaining to LGBTI health(care) vary depending on gender, age, income and disability as well as between LGBTI groupings. Gaps in the literature remain around how these factors intersect to influence health, with further large-scale research needed particularly regarding trans and intersex people. CONCLUSION: Health inequalities can be addressed via changes in policy, research and in practice through health services that accommodate the needs of LGBTI people. With improved training to address gaps in their knowledge of LGBTI health and healthcare, health professionals should work in collaboration with LGBTI people to address a range of barriers that prevent access to care. Through structural change combined with increased knowledge and understanding, services can potentially become more inclusive and equally accessible to all.

Listening for commissioning: A participatory study exploring young people's experiences, views and preferences of school-based sexual health and school nursing.

AIMS AND OBJECTIVES: To explore the experiences, views and preferences of young people aged 11-19 years regarding school-based sexual health and school nursing to inform commissioning and delivery for one local authority area in England during 2015. BACKGROUND: Promoting sexual health for young people remains a challenging, even controversial, but important public health issue. Concerns regarding accessibility, acceptability and efficacy in school-based sexual health and school nursing are evident in the literature. Additionally, a complex public health policy context now governs the funding, provision and delivery of sexual health and school nursing, which potentially presents further challenges. DESIGN: A qualitative, participatory design was used to explore sexual health and school nursing. Data were generated from 15 focus groups (n = 74), with young people aged 11-19 years, in educational-based settings in one local authority area in England. RESULTS: The resultant themes of visibility in relation to sexual health education and school nursing revealed both the complex tensions in designing and delivering acceptable and appropriate sexual health services for young people and the significance of participatory approaches. CONCLUSION: Our study shows the importance of participatory approaches in working with young people to clearly identify what they want and need in relation to sexual health. The findings also confirm the ways in which school-based sexual health remains challenging but requires a theoretical and conceptual shift. This we argue must be underpinned by participatory approaches. RELEVANCE TO CLINICAL PRACTICE: School nurses have always had a significant role to play in promoting positive sexual health for young people and they are exceptionally well placed to challenge the risk-based cultures that frequently dominate school-based sexual health. A shift of debates and practices towards the promotion of positive sexual health cultures though previously argued for now requires the active engagement and involvement of young people.

Queer challenges to evidence-based practice.

This paper aims to queer evidence-based practice by troubling the concepts of evidence, knowledge and mental illness. The evidence-based narrative that emerged within biomedicine has dominated health care. The biomedical notion of 'evidence' has been critiqued extensively and is seen as exclusive and limiting, and even though the social constructionist paradigm attempts to challenge the authority of biomedicine to legitimate what constitutes acceptable evidence or knowledge for those experiencing mental illness, biomedical notions of evidence appear to remain relatively intact. Queer theory offers theoretical tools to disrupt biomedical norms and challenges biomedical normativity to indicate how marginalisation occurs when normative truths about mental health classify those who differ from the norm as 'ill' or 'disordered'. Queer theory's emphasis on normativity serves the political aim to subvert marginalisation and bring about radical social and material change. Reference will be made to mental health subjects within each discourse by indicating how the body acts as a vehicle for knowing. Deleuzian notions of the rhizome are used as metaphor to suggest a relational approach to knowledge that does away with either/or positions in either biomedical, or queer knowledge to arrive at a both/and position where the biomedical, constructionist and queer are interrelated and entangled in needing the other for their own evolution. However, queer does not ask for assimilation but celebrates difference by remaining outside to disrupt that which is easily overlooked, assumed to be natural or represented as the norm. The task of queer knowledge is to do justice to the lives lived in the name of evidence-based practice and demands that we consider the relations of power where knowledge is produced. This pursuit creates different knowledge spaces where we identify new intersections that allow for socially just understandings of knowing or evidence to emerge.

The resilient subject: exploring subjectivity, identity and the body in narratives of resilience.

International research and policy interest in resilience has increased enormously during the last decade. Resilience is now considered to be a valuable asset or resource with which to promote health and well-being and forms part of a broader trend towards strength based as opposed to deficit models of health. And while there is a developing critique of resilience's conceptual limits and normative assumptions, to date there is less discussion of the subject underpinning these notions, nor related issues of subjectivity, identity or the body. Our aim in this article is to begin to address this gap. We do so by re-examining the subject within two established narratives of resilience, as 'found' and 'made'. We then explore the potential of a third narrative, which we term resilience 'unfinished'. This latter story is informed by feminist poststructural understandings of the subject, which in turn, resonate with recently articulated understandings of an emerging psychosocial subject and the contribution of psychoanalysis to these debates. We then consider the potential value of this poststructural, performative and embodied psychosocial subject and discuss the implications for resilience theory, practice and research.