Mental disorders and help seeking for mental or physical health conditions in sexual minorities

The Division of Psychiatry at UCL’s legal basis for processing personal data under GDPR is function of a public task (by a public organisation) as set out in Article 6(1), point (e) (“necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller” “and the task or function has a clear basis in law.”) and Article 9(2), point (j) (“necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes”). It is in the public interest because the analysis of these data may allow the researchers to investigate whether sexual minorities have worse mental health than heterosexuals and the factors that are associated with this.

The Division of Psychiatry at UCL has a 20 year history of research into LGBT (lesbian, gay, bisexual, and transgender) mental health and well-being. The Adult Psychiatric Morbidity Survey (APMS) in 2007 was the first time that questions on sexual orientation were included in such a national survey. The chief investigator for this project from UCL collaborated with the survey makers (NatCen) on the most appropriate wording for questions about sexual orientation. Thus, UCL has a long history of research in this field and particularly in collaboration with the APMS survey. University College London will serve as both data processor and controller.

There are many positive aspects to being gay. Evidence suggests that lesbians and gays may be more resourceful and self-reliant, have a wider circle of supportive friends and more disposable income then heterosexuals. However there is also evidence that people who self-identify as gay or lesbian have poorer psychological health and lower social well-being then the heterosexual population in modern Britain. This is puzzling as recent social attitudes to same/sex relationships have become much more positive. The last Adult Psychiatric Morbidity Survey was the first national survey of its kind in the UK to include questions on sexual minority status. The results showed an excess of mental disorder of all types in the lesbian gay and bisexual population (Chakraborty et al 2010). The current research seeks to discover whether this has changed and, in particular, whether mental distress maybe less common in younger generations who have experienced less negative social attitudes.

There is considerable evidence that people who identify as LGBT suffer higher rates of mental disorder than their heterosexual counterparts. However, the sample populations studied are often not probabilistic, the origins of this distress are not always clear and it is not known whether higher levels of distress fall as societies become more accepting of same sex couples. UCL therefore have planned a research study with the following aims:

1. To compare rates of mental disorders and help seeking for mental or physical health conditions in non-heterosexual and heterosexual people in 2007 and 2014.

2. To model predictors of mental distress, well-being and help seeking in non-heterosexual people

The predictors identified, and the interventions suggested to modify them, will have important clinical and public health implications. This study therefore has significant potential to address health inequalities.

The study population consists of people aged less than 65 years (people aged 65+ were not asked about their sexuality in 2014) who responded to either the 2007 or 2014 Adult Psychiatric Morbidity Survey (APMS). The study design takes the form of cross-sectional studies carried out in England.

All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract ie: employees, agents and contractors of the Data Recipient who may have access to that data).

The 2014 APMS data set is held on behalf of NHS Digital by the UK Data Service (UKDS) (www.ukdataservice.ac.uk ) and UKDS are responsible for dissemination under direction by NHS Digital. UCL will get the whole data set; there is no facility to select individual variables. UCL will be able to download the data set from UKDS for the period specified within the DSA and must securely destroy all local copies of the data set when the DSA expires and notify NHS Digital in line with standard procedures. This 2014 version of the data set available has been redacted on Disclosure Control Procedure advice to minimise the likelihood of individuals being able to identify anyone taking part in the survey.

Since the active data sharing agreement has been in place, UKDS has transferred the pseudonymised APMS data to UCL. It has been transferred and accessed within the Data Safe Haven. This is UCL's data service for storing, handling and analysing identifiable data. It has been certified to the ISO27001 information security standard and conforms to NHS Digital's Information Governance Toolkit.

The data transferred from UKDS to UCL data safe haven contains survey data that is potentially identifiable. This transfer will be governed by accepted, standard procedures used by UCL Data Safe Haven identifiable data transfer portal and described on their website: http://www.ucl.ac.uk/isd/itforslms/services/handling-sens-data/tech-soln. Data will also be stored in the UCL Data Safe Haven which is DTSP Toolkit assured, dual-factor authenticated, access is determined on a need-to-know basis, firewall has a default deny policy, data enters via a managed file transfer mechanism and only the information asset owner has permission by default to draw down any data. All those on the study team who will analyse data are required to complete Data Security Training, as provided by Health Education England, and to complete the authorisation process. Data will be destroyed in time for the termination of the Data Sharing Agreement with NHS Digital so that only the outputs remain. A notice of destruction will be issued in writing to confirm, 90 days after the user has clicked ‘delete’, once the backup cycle has overwritten the files and the data have not been restored in the intervening time.

All analyses will make use of the weightings provided with the data sets to give results that are applicable to the population and account for the primary sampling unit. New weightings for the 2007 survey, provided in 2016 will be used. Descriptive statistics will also be carried out unweighted (representing those in the data sets only). All weighted analyses will be carried using Stata version 14 survey (svy) commands.

Descriptive analysis

Descriptive analyses will be undertaken for each survey (2007 and 2014) as well as in the whole data set combined. However for some of the variables below, it will not be possible to examine these by year of survey because questions were changed somewhat between surveys. If any particular outcome from those noted above is not available for either year, it will only be reported in the analysis for the year it is available.

Variables to be included:

Social, demographic and personal: such as age, sex, children, and social support.

Mental health outcomes:

The main outcome of interest is what is called common mental disorder. This is a variable which combines all the diagnoses which come under the general rubric of depression and anxiety. Other factors such as severe mental illness, self-harm and drug use will also be examined. However UCL do not wish to lose sight of positive factors such as emotional well-being and will also present group comparisons on these measures.

Help-seeking and use of services:

The 2014 APMS data set is rich in information on reported help seeking and so UCL shall explore to what extent people have received counselling, their contacts with primary medical care and social care services, and whether they have been admitted to hospital.

Other variables:

UCL will also explore difference between heterosexual and non-heterosexual people on factors such as spiritual beliefs and religious practice.

The differences between the data contained in the 2007 and 2014 APMS will enable UCL to examine change with time in terms of what is called ‘period effects’, to determine whether there are differences for people of similar age and background between the two time points.

In more sophisticated analyses UCL will explore the possible reasons for hypothesised elevated rates of psychological distress in LGB people, for example discrimination, childhood abuse and neglect, parenting, interpersonal violence, and bullying. UCL will examine the effect of age, sex and general health on the associations observed and where possible examine men and women separately. In some instances this may be limited by numbers. If numbers become very small in sub-categories, UCL shall amalgamate the two groups into the more general comparison of heterosexual versus non-heterosexual.

There will be no data linkage undertaken with NHS Digital data provided under this agreement that is not already noted in the agreement.

Data will only be accessed and processed by substantive employees of University College London and will not be accessed or processed by any other third parties not mentioned in this agreement.

This research will only report aggregate data showing patterns overall; meaning no individual will be able to be identified.

All outputs will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide.

The results of this research will be published in high-impact peer-reviewed journals and presented at conferences (for example, the Royal College of Psychiatrists Annual International Congress; the Health Studies User Conference). In particular, results will be published in journals concerned with mental health and medical practice. The peer-reviewed articles will be available on the UCL repository giving free access to either the published article or the accepted manuscript depending on the journal. The aim is to have the work published by the end of 2025.

To reach a broader audience UCL will also use Twitter, UCL blogs, Mental Elf blogs, and media such as “The Conversation” to disseminate the key messages of our research, and their clinical implications.

Organisations involved in implementation include the Royal College of Psychiatrist, the Mental Health Foundation and Stonewall. The principal investigator (PI) for this project was on the Executive of the Royal College of Psychiatrist’s Special Interest Group in LGB mental health.

The analysis of these datasets may allow the Division of Psychiatry to investigate whether sexual minorities have worse mental health than heterosexuals and the factors that are associated with this. The greater statistical power that the APMS datasets afford the Division of Psychiatry means that UCL will be able to conduct these investigations both as a two-group comparison (sexual minorities and heterosexuals) but also by comparing the mental health of specific subgroups of the sexual minority population. This is important as previous research using non-representative samples has suggested that bisexual people have worse mental health, but this requires testing using a large sample involving probabilistic sampling. Another advantage of UCL's approach is that the Division of Psychiatry may investigate both mental health and also positive aspects of wellbeing and resilience, and whether there have been changes since the 2007 survey. This assets-based approach is a key issue for the health of sexual minorities.

Division of Psychiatry's team have close links with the UK Government’s Equalities Office (GEO) and a range of third sector organisations advocating for sexual minority groups, as well as public health agencies. This is evidenced in the Division of Psychiatry's knowledge exchange and transfer activities, including those using the media reach of the UKRI-funded Loneliness and Social Isolation in Mental Health research network. From these links the Division of Psychiatry are clear that the planned work meets the Government’s remit to understand disparities between the mental health of sexual minorities and heterosexuals in more detail and using robust methods. The government recently published a large survey of the health of sexual minorities [https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-england-additional-analyses/lesbian-gay-and-bisexual-adults#chapter-index] but this is a much less representative sample of LGBT people than those in the APMS study. Thus, the Division of Psychiatry's APMS analysis may be an important contribution to the current state of knowledge. The Division of Psychiatry's early findings from this project received significant media attention on Twitter and was widely covered in the national and local press (https://www.altmetric.com/details/100297930/news) and by LGB organisations. One of the Division of Psychiatry team was interviewed on LBC news, and our work has been discussed in blogs for BACP Therapy Today, UCL and the University of East Anglia.

o LBC News interview with Martin Stanford: https://www.globalplayer.com/catchup/lbcnews/uk/7UN7tH1m/

o Cited in BACP blog: https://www.bacp.co.uk/bacp-journals/therapy-today/2021/june-2021/the-big-issue/

o UEA blog: https://www.uea.ac.uk/news/-/article/mental-health-disorders-and-alcohol-misuse-more-common-in-lgb-people

o UCL blog: https://www.ucl.ac.uk/news/2021/feb/mental-health-disorders-and-alcohol-misuse-more-common-lgb-people

Professor Michael King has previously presented research findings demonstrating the mental health inequalities experienced by LGBT people to Royal Colleges, the Department of Health and Social Care and the Church of England. Members of the Division of Psychiatry team continue to work with the GEO to advise on the implications of our findings for acceptable and effective interventions to improve LGB mental health. These policy links will enhance the application of our research findings on effective interventions to policy developments.

As lead of the Royal College of Psychiatrists Rainbow Special Interest Group Prof Michael King has already presented at the RCPsych International Congress to highlight inequalities in the mental health of sexual minorities compared with heterosexuals to central policymakers and clinicians in NHS trusts nationally. The Division of Psychiatry have plans to present at future RCPsych International Congresses as well as the annual meeting of the World Association of Social Psychiatry. Beyond publishing the Division of Psychiatry study findings in leading journals such as Psychological Medicine, Lancet Psychiatry, the British Journal of Psychiatry, and World Psychiatry we will continue to use the media reach of the UCL Institute of Mental Health and the Loneliness network to reach wider audiences (for example: https://www.ucl.ac.uk/psychiatry/pathways-plus-projects-blog-gemma-lewis), including policymakers, sexual minority groups, the organisations that advocate for them, and clinicians internationally. The clinical experience within the Division of Psychiatry multidisciplinary team will maximise the chances of our findings being translated into clinical and public health recommendations regarding interventional work. The Division of Psychiatry's links with the PRIMENT Clinical Trials Unit will improve the chances of successful applications for trial funding to evaluate such interventions. This APMS work therefore represents an important foundation for future work to benefit the health of LGB people, in line with the government’s LGBT Action Plan 2018, including relevant updates to the devolved nations’ suicide prevention strategies.

UCL may take action to improve mental healthcare for LGBT people. The Department of Health and Social Care and the Government Equalities Office will jointly develop a plan focused on reducing suicide rates amongst the LGBT population. The Department of Health and Social Care may ensure LGBT people’s needs are addressed in the updated Suicide Prevention Strategy, and the new Health Education England suicide prevention competency framework may cover high-risk groups including LGBT people.

The British Social Attitudes survey suggests there have been large positive changes in the UK and other western societies in terms of acceptance of LGBT rights, including equal marriage and the Equality Act. Thus, society should have begun to see changes in their mental health. However, members of the Division of Psychiatry team’s recent analysis of data from an English birth cohort of non-heterosexual people aged 20 (the Avon Longitudinal Study of Parents and Children, ALSPAC) indicates that levels of psychological distress remain markedly elevated over that of their heterosexual peers (Irish et al, 2019). This is puzzling and needs replication in a national sample that is more representative of England. If the Division of Psychiatry's team find a similar picture in the APMS data, available covariates will need to be explored in more detail to understand what explains this pattern. This work may inform more targeted prevention, as well as support and treatment for those affected in the general population.

The 2007 APMS was the first survey to ask a question about sexual orientation and so the results of the Division of Psychiatry team’s analysis (which combines the 2007 and 2014 surveys) of mental health and service use in LGB people may be crucial in determining how local services, schools and the wider community can best act together to improve the health of sexual minorities. This may involve health and wellbeing campaigns that are directed at the whole community and not just LGB groups, who unfortunately remain too often the targets of exclusion and discrimination.

The first paper in Psychological Medicine, 'The mental health of lesbian, gay, and bisexual adults compared with heterosexual adults: results of two nationally representative English household probability samples' received significant attention in the print and internet media (https://www.cambridge.org/core/journals/psychological-medicine/article/mental-health-of-lesbian-gay-and-bisexual-adults-compared-with-heterosexual-adults-results-of-two-nationally-representative-english-household-probability-samples/7F7D9F957CBD9C03395FF715792682F6).

The Division of Psychiatry have not been able to do other work set out the protocol as our job plans involved redeployment due to COVID-19 and as this work is unfunded UCL were unable to give it greater priority. However, The Division of Psychiatry are now focused on addressing the remaining research questions and dissemination the findings to the policy, research and lived experience communities.