It may seem that there has never been a better time to identify as Lesbian, Gay, Bisexual or Transgender (LGBT). Same-sex marriage is now legal, anti-discrimination laws offer more protection, and more people are out and proud in the public eye than ever before. Yet a significant new report out last week confirms what many feared. London's LGBT population are living in ever worsening conditions, with more complex needs. Worse, the specialist support people want is being eroded.
Austerity measures have hit many marginalised communities disproportionally. One third of London's LGBT community now have an income of under £15,000 per annum, below the minimum wage. LGBT service providers report more people struggling with multiple needs such as substance misuse problems, poverty, disability and mental health issues. Despite the rhetoric of progress, 40% of the LGBT population experience prejudice regularly, with a third routinely fearing for their physical safety, either at home or in public.
There has been a huge reduction in specialist provision over the past few years, with 90% of providers stating trying to achieve adequate funding is their biggest problem, and over half having to implement dramatic cost-cutting measures. Two of the seven organisations behind last week's report - the only national LGBT domestic violence charity, Broken Rainbow, and community stalwart PACE - have had to close their doors. This in times where every single LGBT service provider is reporting a greater demand, and need to turn people away. This despite consistent evidence the majority of the LGBT population would prefer specialist services.
Why shouldn't the LGBT population access mainstream services instead? Well, homosexuality was seen as a diagnosable mental disorder until relatively recently, and there are reasons for distrust in mainstream services to continue. A large proportion of LGBT patients have experienced homophobia, biphobia or transphobia from NHS staff. A majority feel the need to mask their sexual or gender identity. Many fear, sometimes correctly, that staff's religious beliefs may mean they view homosexuality as a sin.
The fear is perhaps worse in mental health services, where diagnosis and treatment is based on comparison to norms, and thus shaped by attitudes and presumptions. Staff members still sometimes erroneously situate bisexuality, for example, as an indicator of mood instability or so-called personality disturbance. Or assume that all sex is consensual if group sex and drugs are involved. Gender fluidity may have reached the pages of Grazia magazine, but it might not have reached your local health centre. And even if it maybe has, many will not risk finding out, without the clear messages of acceptance one finds in specialist services.
Yet this heady mix of austerity cutbacks and institutional homophobia is not the only reason for the current crisis. As trust in professionals has waned, evidence-based medicine (EBM) has become the 'gold standard' of health and social care, an approach which sells itself on its objectivity. EBM is intended to optimise decision-making by using quantitative research for empirical support to ward off bias. Top points go to research which has a large participant population and a very tight, precise intervention so replicability can be assured. Now finding similar populations in mental health is notoriously difficult, as is offering the same intervention, but some services like IAPT do it better than others by providing treatment protocols for problems like anxiety, and manuals for clinicians to direct what they do session by session. As EBM is based on norms, it favours larger homogenous populations, allowing Lord Layard - for example - to promise millions can be cured with a particular approach (it turns out, a little too optimistically).
When money is tight, commissioners give funding to services best able to play the EBM game, at the expense of those which serve smaller, more diverse populations such as LGBT and BAME specialist services. Grassroots organisations are structurally unable to play the numbers game as well, meaning their services lose funding disproportionally (even when they have better results for a specific demograph).
This problem is not just experienced by LGBT specialist services, but many providers that focus on intersectionality, the 'too complicated' cases where multiple, clashing discriminations such as racism and sexism interact with social disadvantage to create a perfect storm for embodied distress. We cannot afford to lose these organisations. It is these services, so embedded in their communities, which are best able to respond quickly to change. The sudden rise of chemsex in the gay community? A new refugee population due to a war elsewhere? It is grassroots services that respond first, reaching out and pioneering new approaches often years before mainstream services, and educating the NHS in turn.
Social media gives us the impression that we live in a time of freedom, where diversity is celebrated, where refuge can be found with like-minded souls, where help for mental anguish is available. Yet the lived experience of many in the LGBT population is of ever greater poverty, more complex problems, more oppression, and less support. We must recognise that making funding decisions based on EBM produces a bias against those most disadvantaged, a bias against difference that should not be acceptable in any society that we can call progressive.
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