Response 57734071

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About You

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Maruska Greenwood

3. Are you responding as an individual or an organisation?

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4. What is your organisation?

LGBT Health and Wellbeing

5. The Scottish Government would like your permission to publish your consultation response. Please indicate your publishing preference:

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1. Our framework sets out 8 priorities for a new Mental Health Strategy that we think will transform mental health in Scotland over 10 years. Are these the most important priorities?

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If no, what priorities do you think will deliver this transformation?
Of the priorities outlined in the Strategy our comments are primarily focused on Priority 4 (supporting self management) and Priority 5 (improving access to efficient, effective and safe services), as these are the priorities that have the most specific relevance to LGBT adults. The aim of embedding a human rights-based approach (Priority 8) will provide a much needed focus on equality and non-discrimination, and serve to support some of the recommendations made in our submission in relation to LGBT people. Firstly why is the new Mental Health Strategy of importance to lesbian, gay, bisexual and transgender (LGBT) people in Scotland. Because as a result of stigma and discrimination, LGBT people as a population group experience particularly acute mental health inequalities: • Suicidal behaviour is 3 times more prevalent among lesbian, gay and bisexual (LGB) people when compared to the general population; this rises to 8 times among transgender people. • Self-harm is 8 times more prevalent among LGB people; this rises to 20 times among transgender people. Timely engagement and the availability of accessible mental health support is therefore a crucial issue for LGBT people. The high level of need LGBT people have for mental health support is however coupled with a lower than expected level of engagement with mental health services, particularly prevention and early intervention services, as well as often with poor experience of these services. Reasons for this are complex, but centre largely on a widespread lack of understanding of the mental health needs of LGBT people and consequently the inability of public and third sector services to respond to these needs proactively and in a culturally sensitive manner. Many people, especially older people, can be reluctant to disclose their LGBT status, including both within primary care and mental health services, having faced discrimination or having had poor experiences of services and support because of their status/identity. In relation to mental health services, poor experiences can include an assumption that LGBT identity and mental health issues are linked, with LGB or T identity viewed by health care staff as a direct cause of poor mental health. This reluctance to disclose LGBT status (to ‘come out’) means that where LGBT people are accessing mental health support they may be invisible (as LGBT) within those support services.

2. The table in Annex A sets out a number of early actions that we think will support improvements for mental health.

Are there any other actions that you think we need to take to improve mental health in Scotland?
Below is our response in relation to how some of the priorities in the new Mental Health Strategy can be made a reality for LGBT people: PRIORITY 4: Support people to manage their own mental health LGBT Health works to address the health inequalities experienced by LGBT people in Scotland. Our work with individuals is largely focused on promoting emotional and mental wellbeing, reducing isolation, building resilience and providing individuals with a much needed sense of affirmation and belonging that serves to counter the negative social attitudes that are still too prevalent in Scotland today. In essence our work is about repairing the real damage inequality does to the mental health of individuals; this work has a strong emphasis on promoting peer support and self-management. In addition to working with individuals we also work with service providers to enable them to become more inclusive. We are currently delivering the Scottish Government-funded LGBT Mental Health Capacity Building Project which support mainstream mental health service providers to become more culturally competent in meeting the needs of LGBT service users. Peer Support and Information Through LGBT Health’s work with LGBT people or those questioning their sexual orientation or gender identity, we’ve consistently found that the peer support provided by other LGBT people is crucial in enabling individuals to build a positive identity and self-esteem. For LGBT people peer support crucially provides affirmation and a sense of community and belonging. Yet, as for example our recent Fife LGBT Needs Assessment Report (LGBT Health, 2016) indicates, social opportunities to meet with peers are not necessarily available to LGBT people in every part of Scotland. Whilst LGBT people in general report high levels of isolation, recognised as a key risk factor for poor mental health, those in rural areas report significantly higher rates of isolation compared to LGBT people in urban areas (The 2015 Scottish LGBT Equality Report found 47% of LGBT people in rural areas and 23% of those in urban areas reported feeling isolated where they live). In terms of information provision to support self management, our Fife LGBT Report found individuals very much wanted LGBT-specific health information, including in relation to mental health matters (66% of respondents wanted this, rising to 94% of those who reported they had a mental health condition). Supporting Self-management For mental health and support services to effectively support LGBT people to manage their own mental health, it is important for service providers to understand the impact of stigma, prejudice, disadvantage and discrimination on the mental health of many LGBT individuals. Despite very significant improvements in social attitudes, as a result of ongoing discrimination, it is still the case that LGBT people experience much higher rates of poor mental health, depression, psychological distress, suicidal behaviour and self-harm than the general population. Poor emotional wellbeing and mental health is often prevalent among young LGBT people, including around first ‘coming out’ and is frequently linked or exacerbated by school bullying, yet commonly continues into adulthood. Those coming out later in life, particularly where lack of opportunities to meet other LGBT people is an issue, can equally also experience challenges around developing a positive sense of identity. Effectively supporting LGBT people to self manage will therefore mean addressing issues of isolation, access to peer support - including other LGBT people - and LGBT-specific information and services that are inclusive and responsive to the needs of LGBT people. PRIORITY 5: Improve access to mental health services and make them more efficient, effective and safe – which is also part of early intervention. Accessibility of Mental Health Services Timely engagement and availability of mental health support is clearly a crucial issue for LGBT people. However even where services are available, prejudice and discrimination mean LGBT people experience significant access barriers (The 2015 Scottish LGBT Equality Report found 21% of LGBT people had experienced discrimination or less good treatment within healthcare services). Discrimination or poor experiences of services makes people reluctant to access services, as well as unwilling to disclose their status. People not feeling able to disclose their LGBT status, and therefore talk freely about some of the issues and challenges that this might bring, as well as their families of choice and those that can support their recovery, clearly creates significant barrier to effective treatment. People being reluctant to seek support at an early stage, means opportunities for prevention and early intervention are lost, and means individuals are more likely to present once their mental health challenges have become more protracted or they are in crisis. Need for Equality Monitoring It is crucial that national outcomes data includes equality monitoring of sexual orientation and gender identity. Routine monitoring of sexual orientation and gender identity will enable us to make progress in better understanding the demand, need, service uptake and outcomes for LGBT populations. Demonstrating outcomes for LGBT communities is crucial because LGBT people are both more likely to have a mental health problem and yet are less likely to access services. Without this equality monitoring we will be unable to benchmark the levels of engagement in services and the experiences of LGBT people within services, thus making it challenging to identify critical issues, such as lack of access or poor outcomes, and consequently to allocate resources effectively to areas of need. Benchmarking, and thus monitoring and measuring progress in relation to addressing the mental health inequalities experienced by LGBT people, will only be possible if equality data is routinely collected. The proposed indicators to measure clinical and personal mental health outcomes should be appropriate to different minorities and population groups. Safety of Mental Health Services Making mental health services safe for LGBT people means making those services free from prejudice and discrimination. In the recent ‘LGBT experiences of psychiatric wards’ consultation (Mental Welfare Commission and LGBT Health, July 2016) participants spoke of ongoing institutional homo/bi/transphobia, lack of understanding from health care professionals of LGBT identities and the negative impact prejudice and discrimination can have on self-esteem, sense of identity and mental health. LGBT participants discussed experiencing instances where their safety was not protected, such as when transphobic and homophobic comments and behaviour from other patients are brushed off by staff (because ‘they’re not well’), rather than challenged. The staff’s poor understanding of LGBT identities can leave individuals feeling belittled, vulnerable and serve to further undermine their confidence and mental health. Ignorance and prejudice are often particularly acute around transgender issues; for example, a lack of understanding as to how the absence of privacy in an acute ward is particularly difficult for a transgender patient experiencing body dysmorphia. Patients can also encounter an assumption that their LGBT identity and mental health issues are linked, with staff for example focusing on the issue of gender reassignment when this is not necessarily relevant to the mental health of the patient. OUTCOME 6: Improve the physical health of people with severe and enduring mental health problems to address premature mortality. Our public health strategy need to deliver health improvements for all people living with mental health problems. To achieve this we need to have cognisance of the additional access barriers for LGBT people, who experience both high levels of poor mental health, but also additional challenges in achieving and maintaining good physical health, including lower uptake of prevention initiatives and higher rates of alcohol use and smoking. Consideration thus needs to be given to how prevention programmes can achieve the desired uptake among LGBT people, including looking at the scope for specialist initiatives to increase uptake. For example, LGBT identity, and the experience of prejudice and disadvantage likely to be coupled with this, may be key factors in an individual’s smoking and alcohol use; therefore successful prevention programmes should be able to address this with cultural sensitivity and enable individuals to explore their individual experiences in a way that does not further stigmatise or disadvantage them. OUTCOME 8: Realise the human rights of people with mental health problems. For LGBT people with mental health problems to experience less discrimination, fewer health inequalities, improved access to mental health services, and improved employment we need to develop our workforce to be able to deliver more inclusive services.

3. The table in Annex A sets out some of the results we expect to see.

What do you want mental health services in Scotland to look like in 10 years' time?
The Scottish Government’s 10 year vision to transform mental health needs to be ambitious; we warmly welcome its focus on human rights, non-discrimination and equality. However we need to recognise lesbian, gay, bisexual and transgender people as a particular risk group for poor mental health. Much clearly needs to be done within mental health services, and indeed more broadly, to successfully address the acute mental health inequalities experienced by LGBT people. To help achieve this we would welcome a focus on the following areas in the forthcoming Mental Health Strategy for Scotland: • Inequalities: ensure focus on areas of need and populations with pressing mental health inequalities. • Equality monitoring: routine monitoring of sexual orientation and gender identity to better understand demand, need, service uptake and outcomes. • Access barriers: work to address access barriers to ensure opportunity for prevention and low-level intervention are not lost. • Workforce development: to ensure culturally appropriate inclusive and welcoming service response.