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Intertasc Report Format UNIVERSITYOF BIRMINGHAM A systematic review of lesbian, gay, bisexual and transgender health in the West Midlands region of the UK compared to published UK research Catherine Meads, Mary Pennant, James McManus & Sue Bayliss Department of Public Health and Epidemiology West Midlands Health Technology Assessment Group DPHE 2009 Report Number 71 A systematic review of lesbian, gay, bisexual and transgender health in the West Midlands region of the UK compared to published UK research A WEST MIDLANDS HEALTH TECHNOLOGY ASSESSMENT COLLABORATION REPORT Report commissioned by: Regional Evaluation Panel Produced by: West Midlands Health Technology Assessment Collaboration Unit of Public Health, Epidemiology and Biostatistics The University of Birmingham Authors: Catherine Meads, Lecturer in HTA Mary Pennant, Systematic Reviewer James McManus, Director of Public Health Sue Bayliss, Information Specialist Correspondence to: Dr Catherine Meads Unit of Public Health, Epidemiology and Biostatistics University of Birmingham Edgbaston, Birmingham, B15 2TT Tel 0121-414-6771 [email protected] Date completed: March 2009 Expiry Date: March 2011 Report Number: 71 ISBN No: 0704427222 9780704427228 © Copyright, West Midlands Health Technology Assessment Collaboration Unit of Public Health, Epidemiology and Biostatistics The University of Birmingham 2009 LGBT health WEST MIDLANDS HEALTH TECHNOLOGY ASSESSMENT COLLABORATION (WMHTAC) The West Midlands Health Technology Assessment Collaboration (WMHTAC) produce rapid systematic reviews about the effectiveness of healthcare interventions and technologies, in response to requests from West Midlands Health Authorities or the HTA programme. Reviews usually take 3-6 months and aim to give a timely and accurate analysis of the quality, strength and direction of the available evidence, generating an economic analysis (where possible a cost-utility analysis) of the intervention. CONTRIBUTIONS OF AUTHORS: Catherine Meads wrote the protocol, conducted some web searches, made inclusion/exclusion decisions, data extracted quantitative data, wrote the quantitative part of the review and discussion and acts as guarantor. Mary Pennant critically appraised the protocol, made inclusion/exclusion decisions, checked the quantitative data extraction, wrote the qualitative systematic review and commented on the final report. James McManus wrote the legal section and peer reviewed the report. Sue Bayliss devised and ran search strategies and made comments on the final report CONFLICTS OF INTEREST: None ACKNOWLEDGEMENTS: The requesters of this report included Professor David Cox, Chair of South Birmingham PCT and Cynthia Bower, Chief Executive of NHS West Midlands. Many thanks to David Moore for including this report in the REP series and to David Moore, Professor David Cox and Janet Fox for critically appraising the protocol. Many thanks to Christine Burns, Bridget Candy, Ruth Garside, David Moore, and Justin Varney for peer reviewing the final report. II LGBT health GLOSSARY/ABBREVIATIONS AND ACRONYMS Abbreviation/Acr Definition onym AIDS Acquired Immune Deficiency Syndrome BMC BioMed Central BME Black and Minority Ethnic BMI Body Mass Index CASP Critical Appraisal Skills Programme cc Cubic centimetres CDSR Cochrane Database of Systematic Reviews CP Civil Partnership DARE Database of Reviews of Effects DV Domestic Violence GHB Gammahydroxybutyrate GHQ-12, GHQ-28 General Health Questionnaire (measure of mental health) with 12 or 28 questions GP General Practitioner HIV Human Immunodeficiency Virus HTA Health Technology Assessment I2 I squared measure of heterogeneity between studies ICD-10 International Classification of Diseases – 10th Revision ISBN International Standard Book Number LGB Lesbian, gay and bisexual LGBT Lesbian, gay, bisexual and trans LSD Lysergic Acid Diethylamide MA Master of Arts MeSH Medical Subject Heading MSM Men who have sex with men MSWM Men who have sex with women and men MSW Men who have sex with women N, n Number NATSAL National Sexual Attitudes and Lifestyles (Survey) NICE National Institute for Health and Clinical Excellence ONS Office for National Statistics PCO/PCOS Polycystic ovaries/ polycystic ovary syndrome PCT Primary Care Trust SCI Science Citation Index SD Standard Deviation SSCI Social Science Citation Index STI Sexually Transmitted Infection U/S Ultrasound WSM Women who have sex with men WSMW Women who have sex with men and women WSW Women who have sex with women III LGBT health EXECUTIVE SUMMARY Background It is estimated that approximately 3-8% of the UK population identify as lesbian, gay, bisexual or trans (LGBT). Until now, most health research on gay and bisexual men has been around HIV, AIDS and sexually transmitted diseases and for trans people has been on the transitioning process only. However, it has been apparent to the LGBT community that that there are a wide variety of other physical and mental health issues that are also important and that the proportion of gay and bisexual men who have HIV/AIDS is relatively small. Very little general LGBT health research has been published so far and there are very few health services that specifically address the general health concerns of the LGBT community. This systematic review presents all available research conducted in the West Midlands on LGBT health since 2000. Local health research is compared to UK national, peer reviewed and published LGBT health research in order to determine whether the local results are unusual compared to national LGBT data, and to routinely collected data on the UK population, where appropriate, in order to determine whether and where the LGBT population differ from the general population. Only UK research has been included because there was no previous UK- specific systematic review so it was unclear how generalisable foreign research would be to the UK. Methods A protocol was developed and underwent NHS peer review. Searches were conducted in a variety of standard databases including the Cochrane Library, MEDLINE, EMBASE, PsychINFO to May 2008. Internet searches were conducted in appropriate specialist websites and extensive contact was made with experts. Included were West Midlands surveys, systematic reviews with UK studies and peer reviewed and published UK quantitative and qualitative primary studies on LGBT people reporting any physical and mental health outcomes, health behaviours and experience of healthcare. Excluded were papers on HIV, AIDS and sexually transmitted diseases, transitioning, non-peer reviewed research, narrative literature reviews without a search strategy, opinion pieces and policy documents. Inclusion IV LGBT health decisions were made in duplicate. Data extraction and quality assessment was conducted by one person and checked by a second, with differences resolved through discussion. Data synthesis was narrative and through the use of data tables. Results were organised by ICD-10 categories. Results Nine West Midlands surveys, two systematic reviews, 11 quantitative and 14 qualitative primary research papers were included, with a wide range of study designs and outcomes measured. Studies were generally of poor quality but unpublished and published LGB results were broadly similar. No results were found on the general health of trans people and very little on people who identify as bisexual. No LGB results were found on many common physical diseases such as chronic obstructive pulmonary disease, digestive diseases or autoimmune diseases, but more on aspects of mental health, health behaviours and use of health services. There were higher rates of breast cancer, mental health problems (depression, anxiety, suicide attempts, eating disorders, self harm) and poor health behaviours (smoking, poor diet, illegal drug use). There were low access rates of cervical screening but no cervical cancer rates in lesbians and bisexual women. There were higher rates of risk factors for cardiovascular disease but almost nothing on the incidence of cardiovascular disease. There was a lower rate of successful hepatitis B vaccination in gay men compared to controls but no follow up research to offer an explanation. A high proportion of LGB people access mental health counselling but many do not find it beneficial. The research on LGB experience of healthcare suggested numerous barriers including homophobia and heterosexism, misunderstandings and lack of knowledge, lack of appropriate protocols, poor confidentiality and the absence of LGBT-friendly resources. Conclusions There is no need for more small surveys on the same aspects of LGBT mental health, health behaviours and experiences of healthcare as these have already been investigated. Further research is needed but must use more sophisticated designs with comparison groups. This systematic review demonstrated that there are so V LGBT health many gaps in knowledge around LGBT health that a wide variety of studies are needed. For example, it is unclear whether the high breast cancer prevalence rates in lesbians and bisexual women are because of high incidence rates or other reasons. It has been presumed that lesbians and bisexual women are at lower risk of cervical cancer than the general population and cervical screening rates are only ~50%, yet there was no information on cervical cancer rates and the fact that a higher proportion of lesbians and bisexual women had heterosexual sex before the age of 16 (43% v 21%) suggests that some lesbians and bisexual women might be at higher rather than lower risk. Large general population
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