TASK 1: State-of-the-art study focusing on the health inequalities faced by LGBTI people D1.1 State-of-the-Art Synthesis Report (SSR) June, 2017 State-of-the-Art Synthesis Report (SSR) © European Union, 2017 Reuse authorised. The reuse policy of European Commission documents is regulated by Decision 2011/833/EU (OJ L 330, 14.12.2011, p. 39). For reproduction or use of the artistic material contained therein and identified as being the property of a third-party copyright holder, permission must be sought directly from the copyright holder. The information and views set out in this report are those of the authors (Laetitia Zeeman, Nigel Sherriff, Kath Browne, Nick McGlynn, Sophie Aujean, Nuno Pinto, Ruth Davis, Massimo Mirandola, Lorenzo Gios, Francesco Amaddeo, Valeria Donisi, Magdalena Rosinska, Marta Niedźwiedzka-Stadnik, Anne Pierson) and do not necessarily reflect the official opinion of the Commission. 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Health4LGBTI website: http://ec.europa.eu/health/social_determinants/projects/ep_funded_projects_en.htm#fragment2 Image provided by: @Delpixel/Shutterstock June 2017 Page 2 of 67 State-of-the-Art Synthesis Report (SSR) Contents Executive summary .................................................................................................... 5 Acknowledgements ..................................................................................................... 8 List of figures ............................................................................................................. 9 List of abbreviations ................................................................................................... 9 Glossary of key terms ............................................................................................... 10 SECTION ONE: Introduction and context ..................................................................... 12 1.1 The Health4LGBTI project .............................................................................................. 12 1.2 The Health4LGBTI Consortium ........................................................................................ 13 1.3 About Task 1 ................................................................................................................ 13 1.4 About this report ........................................................................................................... 14 1.5 A brief note on context and terminology .......................................................................... 16 1.5.1 Health inequalities in context.................................................................................... 16 1.5.2 Terminology ........................................................................................................... 17 SECTION TWO: Methods ........................................................................................... 18 2.1 Introduction ................................................................................................................. 18 2.2 The Scientific Review ..................................................................................................... 18 2.3 The Comprehensive Scoping Review ................................................................................ 18 2.4. The State of the Art Synthesis Report ............................................................................. 19 SECTION THREE: Synthesis of main findings ............................................................... 20 3.1 Introduction ................................................................................................................. 20 3.2 Root causes of health inequalities experienced by LGBTI people .......................................... 20 3.2.1 Heteronormativity .................................................................................................. 21 3.2.2 Heterosexism ......................................................................................................... 22 3.2.3 Victimisation .......................................................................................................... 22 3.2.4 Minority stress ........................................................................................................ 23 3.2.5 Institutional discrimination ....................................................................................... 23 3.2.6 Stigma .................................................................................................................. 24 3.2.7 Summary ............................................................................................................... 24 3.3 What is known about the health inequalities faced by LGBTI people as it relates to healthcare settings? ........................................................................................................................... 25 3.3.1 Lesbian and bisexual women .................................................................................... 26 3.3.2 Gay and bisexual men ............................................................................................. 28 3.3.3 Trans people .......................................................................................................... 32 3.3.4 Intersex people ...................................................................................................... 35 3.3.5 Summary ............................................................................................................... 39 3.4 What is known about the health inequalities of LGBTI people focusing on vulnerable intersections as it relates to healthcare? ................................................................................................... 41 June 2017 Page 3 of 67 State-of-the-Art Synthesis Report (SSR) 3.4.1 People in rural areas ............................................................................................... 41 3.4.2 Refugees and asylum seekers ................................................................................... 42 3.4.3 People with disabilities ............................................................................................. 42 3.4.4 People in socio-economic poverty.............................................................................. 43 3.4.5 Younger people/Older people .................................................................................... 44 3.4.6 Summary ............................................................................................................... 46 3.5 What are the potential barriers faced by: 1) LGBTI people when using or trying to access healthcare and; 2) health professionals when providing care for LGBTI people? .......................... 47 3.5.1 Cultural and social norms ......................................................................................... 47 3.5.2 Language ............................................................................................................... 48 3.5.3 Not knowing and ‘coming out’ ................................................................................... 49 3.5.4 Documentation, health information and protocols ....................................................... 50 3.5.5 Continuity of care ................................................................................................... 50 3.5.6 Knowledge and training ........................................................................................... 51 3.5.7 Summary ............................................................................................................... 53 3.6 What examples of promising practice exist to address the health needs of LGBTI people? ...... 54 SECTION FOUR: Limitations and conclusions ............................................................... 56 4.1 Introduction ................................................................................................................. 56 4.2 Limitations ................................................................................................................... 56 4.3 Conclusions .................................................................................................................. 57 SECTION FIVE: Recommendations ............................................................................. 59 5.1 Introduction ................................................................................................................. 59 5.2 General recommendations .............................................................................................. 59 5.3 Recommendations for training ........................................................................................ 61 REFERENCES ........................................................................................................... 63 Appendices .............................................................................................................. 67 Appendix A: Scientific Review (SR) ....................................................................................... 67 Appendix B: Comprehensive Scoping Review (CSR) ................................................................ 67 June 2017 Page 4 of 67 State-of-the-Art Synthesis Report (SSR) Executive summary AIMS This report is a state-of-the-art review