974 European Journal of Public Health

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The European Journal of Public Health, Vol. 29, No. 5, 974–980
 The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/
4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
doi:10.1093/eurpub/cky226 Advance Access published on 31 October 2018
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Systematic Review and Meta Analyses
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A review of lesbian, gay, bisexual, trans and intersex

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(LGBTI) health and healthcare inequalities
Laetitia Zeeman1,2, Nigel Sherriff1,2, Kath Browne3, Nick McGlynn2,4, Massimo Mirandola5,6,
Lorenzo Gios6, Ruth Davis6, Juliette Sanchez-Lambert7, Sophie Aujean8, Nuno Pinto8,
Francesco Farinella9, Valeria Donisi9, Marta Niedźwiedzka-Stadnik10, Magdalena Rosińska10,
Anne Pierson11, Francesco Amaddeo9, the Health4LGBTI Network

1 School of Health Sciences, University of Brighton, Brighton, UK

2 Centre for Transforming Sexuality and Gender, University of Brighton, Brighton, UK
3 Department of Geography, Maynooth University, Maynooth, Ireland
4 School of Environment and Technology, University of Brighton, Brighton, UK
5 Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
6 CReMPE—Regional Coordination Centre for European Project Management, Veneto Region—Department of Health,
The Verona University Hospital, Verona, Italy
7 European Parliament’s Intergroup on LGBTI Rights, Brussels, Belgium
8 ILGA-Europe, Brussels, Belgium
9 Department of Neuroscience, Biomedicine and Movement, University of Verona, Verona, Italy
10 Institute of Public Health – National Institute of Hygiene, Warsaw, Poland
11 EuroHealthNet, Brussels, Belgium

Correspondence: Laetitia Zeeman, School of Health Sciences, University of Brighton, Falmer, Brighton BN1 9PH, UK, Tel:
+44 1273 644 194, e-mail: l.zeeman@brighton.ac.uk

Background: Lesbian, gay, bisexual, trans and intersex (LGBTI) people experience significant health inequalities.
Located within a European Commission funded pilot project, this paper presents a review of the health
inequalities faced by LGBTI people and the barriers health professionals encounter when providing care.
Methods: A narrative synthesis of 57 papers including systematic reviews, narrative reviews, meta-analyses and
primary research. Literature was searched in Cochrane, Campbell Collaboration, Web of Science, CINAHL,
PsychINFO and Medline. The review was undertaken to promote understanding of the causes and range of
inequalities, as well as how to reduce inequalities. Results: LGBTI people are more likely to experience health
inequalities due to heteronormativity or heterosexism, minority stress, experiences of victimization and discrim-
ination, compounded by stigma. Inequalities pertaining to LGBTI health(care) vary depending on gender, age,
income and disability as well as between LGBTI groupings. Gaps in the literature remain around how these factors
intersect to influence health, with further large-scale research needed particularly regarding trans and intersex
people. Conclusion: Health inequalities can be addressed via changes in policy, research and in practice through
health services that accommodate the needs of LGBTI people. With improved training to address gaps in their
knowledge of LGBTI health and healthcare, health professionals should work in collaboration with LGBTI people
to address a range of barriers that prevent access to care. Through structural change combined with increased
knowledge and understanding, services can potentially become more inclusive and equally accessible to all.
.........................................................................................................

Introduction Major legislative reform in recent years have resulted in signifi-

cant progress towards achieving equality for LGBT people.6
nternational research increasingly demonstrates that lesbian, gay,
Ibisexual, trans and intersex (LGBTI) people are frequently
Acknowledgement of the need to endorse and exercise the rights
of LGBTI people are increasing within the EU where people are
marginalized and experience significant health inequalities.1–6 broadly protected against discrimination on grounds of sexual
Reducing health inequalities is a fundamental goal of public health orientation (lesbian, gay, bisexual people), gender identity (trans
and is regarded by the European Union (EU) as being one of the most people) and sex characteristics (intersex people). However signifi-
important public health challenges facing its Member States.7–9 This cant obstacles remain to full recognition of LGBTI people’s funda-
emphasis is vital as inequalities impact on both the health outcomes of mental rights. These rights include legal recognition of gender,
LGBTI people as well as their experiences of accessing healthcare.10 non-discrimination in the workplace, freedom of expression and
Evidence suggests that LGBTI people are more likely than the general freedom of movement.16 Despite such advances however, social
population to report unfavourable experiences of healthcare including exclusion, stigmatization and discrimination experienced by
poor communication from health professionals and dissatisfaction LGBTI people persist in many healthcare settings.17,18 This is not
with treatment and care received.11–13 LGBTI patients can face bias only a social justice issue, but growing evidence links these experi-
and discrimination in healthcare settings,13,14 with trans patients ences and related minority stress to health inequalities by showing
reporting most dissatisfaction resulting in some avoiding medical that discriminatory behaviour can impact negatively on both mental
treatment, including emergency care.15 health and physical health outcomes.6,19
 A review of LGBTI health and healthcare inequalities 975

As health inequalities have multiple root causes, reducing these systematic reviews in the field published from 2008); and (iv) were
inequalities is complex and there is no simple solution. Moreover, published in English. All editorials, commentaries, non-research and
there is a significant lack of research regarding how to address these theoretical papers were excluded.
inequalities. Indeed, in 2016 this journal noted the need for greater
international research to inform LGBT public health initiatives.20 Data extraction
Tackling inequalities requires a blended approach by addressing the
fundamental causes of inequalities, preventing harmful wider social Eligibility for inclusion was assessed initially (by the first author) by
influences and mitigating against negative effects on individuals.21 screening all identified papers and reports based on titles and
Therefore, this global review was undertaken as part of an EU-funded abstracts. The full text was then obtained for all selected articles

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pilot project that aimed to explore the sources of and modalities for and a second screening performed to determine final eligibility
reduction of LGBTI health and healthcare inequalities by determining: was agreed between the first and second author. Any
(i) what are the causes of LGBTI health inequalities? (ii) What is known discrepancies/disagreements were resolved in consultation with the
about the health inequalities faced by LGBTI people as it relates to third author. The data extraction process is summarized in figure 1.
healthcare settings? (iii) What is known about the health inequalities Geographical restrictions with Europe as a primary focus were
of LGBTI people on vulnerable intersections (e.g. rural, younger, older, applied with a wider international focus where relevant. Of the 57
refugee, those in poverty or disabled)? (iv) What are the potential papers included, 20 were European (any papers that included one or
barriers faced by health professionals when providing care for LGBTI more EU countries), 37 were international (all other countries
people and how can these barriers be addressed? outside Europe which included America, Australia and Canada).

Methods Results
A narrative synthesis design was used to search global literature Studies identified
systematically. This design was chosen due to the complex explora- The first database search on health inequalities and LGBTI people
tory nature of the review which aimed to establish ‘what is known’ (identified as S1 in figure 1) extracted 2058 papers and 357 were
about LGBTI health and healthcare inequalities as well as produce a selected for full-text review with 45 meeting the final inclusion
synthesis of current thinking that cuts across the field offering new criteria. The second database search on health professionals
perspectives and new areas for further research, training and policy including barriers to providing culturally competent care for
development. Whilst such a review may not necessarily provide LGBTI people (identified as S2 in figure 1) identified 903 papers
answers to addressing explicit health problems in given settings, it with 82 selected for full-text review and 12 meeting the final
can nevertheless help policy makers, researchers and practitioners inclusion criteria. Combined, 57 papers were included in this
address concerns that occur across the data.3 In total, 57 relevant review although only the 40 most relevant studies are cited here
papers were extracted and reviewed including: systematic reviews due to journal editorial restriction (for a full list of papers see the
(10), narrative reviews (3), reviews of systematic reviews (2), a Supplementary data). Of the 57 papers, 16 were systematic reviews
meta-synthesis (1) and primary research (41). and/or meta-analyses and narrative reviews that each covered in the
region of 25 research studies or more (16 systematic reviews  25
Search strategy papers each) meant more than 400 research studies were covered by
Systematic searches were carried out using six electronic databases this review. Moreover, papers that were published in addition to
[CINAHL, PsychINFO, MEDLINE (including PubMed), Web of these systematic reviews or following these reviews, that met the
Science, Cochrane Database of Systematic Reviews, Campbell inclusion/exclusion criteria, were also included. Due to the broad
Collaboration Library of Systematic Reviews]. Additional databases scope of the review, database searches were revisited several times to
were excluded to prevent duplication. Google Scholar was searched address gaps in the identified papers for specific (sub)populations
in English and the references of included papers were then checked e.g. the health outcomes of intersex people and their experiences of
to identify further relevant articles. accessing healthcare. These iterative search measures were utilized to
ensure each of the three questions were addressed in sufficient depth.
Furthermore, the terms used to answer the review questions reflect
Key terms the specific groups reported in research. Some papers reported on
Database searches were conducted using various combinations of LGBT people, whereas others referred to LGB people or more spe-
key words and MeSH terms for the three main areas of interest: cifically on trans or intersex people alone. These terms were
health inequalities, the study population (LGBTI people) and honoured as they were presented in the original papers (table 2).
health professionals (healthcare inequalities or barriers to
providing care for LGBTI people). What are the causes of LGBTI health inequalities?
Although some of the search terms used medicalize and or
pathologize sexualities, gender identities and sex characteristics, In general, health inequalities occur due to the consequences of a
these terms were included to ensure the broadest coverage and to complex interaction of social, cultural and political factors. For
expand retrieval. To maximize the number of relevant studies, LGBTI people, the root causes likely to contribute to the
literature searches were conducted in two parts (see figure 1) experience of health inequalities are (i) cultural and social norms
focussing on: search question one (S1) ‘health inequalities and the that preference and prioritize heterosexuality;11,22 (ii) minority stress
study population LGBTI people including vulnerable intersections associated with sexual orientation, gender identity and sex charac-
such as rural, older, refugee, immigrant, disability, poverty’ and; teristics;19,23 (iii) victimization;24 (iv) discrimination (individual and
search question two (S2) ‘the barriers health professionals institutional)6,18 and (v) stigma.17
encounter to providing care for LGBTI people’ (table 1). Health inequalities occur in a context where heterosexuality
prevails as the norm.14,22 LGBTI people access treatment and care
in healthcare settings where it is often assumed that people are het-
Selection criteria erosexual, cisgender (not trans) and not intersex by default.22 These
Papers were considered for inclusion if they: (i) were primary forms of heteronormativity and gender normativity can be
research studies; (ii) reviews, systematic reviews or meta-analyses; understood as beliefs and practices where sex (male and female)
(iii) were published from 2010 onwards to ensure the most recent and gender (masculinity and femininity) are absolute and unques-
studies were captured (except for the inclusion of two pivotal tionable binaries. In heteronormativity opposite sex attraction or
976 European Journal of Public Health

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Figure 1 Selection procedure

heterosexuality is the only conceivable way of being ‘normal’.11,24 As status (e.g. LGB people only account for up to 6% of the UK
LGBTI people deviate from these norms insofar as their sexual population),6 LGB people were among the social groups most
orientation (LGB people), or gender identity (trans people), or sex likely to experience higher levels of unpredictable, episodic and
characteristics (intersex people) they may experience discriminatory day-to-day social or minority stress because of discrimination and
attitudes, prejudice or demeaning behaviour.14,22,24 stigmatization,17,19 which creates a hostile environment where
Discrimination and prejudice sanction the behaviour of those LGBTI people face stressful social exchange.12,19 A meta-analysis of
who deviate from commonly accepted norms. The impact of dis- 386 research studies with LGB people undertaken across 19
crimination is described in minority stress theory, the leading countries, reported up to 55% of people experienced verbal
narrative explaining the health inequalities of LGBTI people.12,19,23 harassment, 45% experienced sexual harassment and 41%
In brief, the minority stress model suggests that because of stigma, experienced discrimination at higher levels than the general
prejudice and discrimination, LGBTI people may experience more population.24 For some LGBT people experiences of individual dis-
stress than non-LGBTI people, and that it is this disproportionate crimination included hostility, personal rejection, harassment,
experience of stress that can lead to increased incidence of physical bullying and violence,18 whilst for others institutional discrimination
and mental health problems.33 Minority stress occurs where occurred where laws and policies in the public domain sustained
marginalized groups display specific risk factors. Whilst the entire inequalities such as the prohibition of same-sex marriage, or
population may display a particular risk factor, the incidence and where laws did not protect against discrimination based on gender
effects of these risk factors may be more pronounced in smaller identity, sexual orientation or sex characteristics.6,18 Globally the
subsections of the larger population.1,19 Due to their minority degree to which LGBTI people are legally protected by anti-
 A review of LGBTI health and healthcare inequalities 977

Table 1 Key terms

Key search terms

1) What is known about the health inequalities faced by LGBTI people as it relates to healthcare settings? (S1)
Lesbian / gay / homosexuala / bisexual / transa / transgender / transsexuala / intersex / hermaphroditism / disorders of sex
development / queer / transvesta / gender identity / questioning / unsure / LGBTI / GLBT / LGB / LGBT / LGBTQ / LGBTU / LGBT & I / same sex / same-sex / sexual
minority / sexual orientation and /
or Health inequalitya/ disparitya / gradient / disadvantagea / determinanta and / or
What is known about the health inequalities of LGBTI people focussing on vulnerable intersections (e.g. rural, older, refugee, immigrant, disability, poverty) as

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it relates to healthcare? (S1)
Intersectiona / rural areas / rural population / rural health / aged / olda / young / disaba/ poverty / migrantsa / immigrants/ asyluma/ refugee / displaced and / or
What are the potential barriers faced by health professionals when providing care for LGBTI people? (S2)
Barriera/ gap / beliefs / attitudes / values / norms / perspective / opinion / heteronormativea / perception Health service accessibility / healthcare accessibility /
health professiona / staff / nursa / doctor / cliniciana

a: Journal requirements allow a maximum of 40 references. The full list and summary of 57 papers are thus provided in an accompanying
Supplementary data.

Table 2 Inclusion and exclusion criteria

Inclusion criteria (S1) Exclusion criteria

Peer reviewed primary research articles published in academic journals, systematic reviews or Grey literature
narrative reviews
Large scope primary research Overly small sample size
Published in English Non-English
Published between 2010 and 2016 Prior to 2010
Social determinants Biological and genetic factors
Physical and mental health Sexual health
Homosexual, bi, trans and intersex Sexual practices [e.g. WSW (women who have sex with
women) and MSM (men who have sex with men) and sex
work]a
Physical conditions including general health profile, cancer, weight discrepancies HIV/AIDS and other STIsb
Mental conditions including suicide, depression, anxiety, mental distress, self-harm, substance
misuse
Rural, geographically remote areas Urban areas
Over the age of 18 as per age of consent in EU MS5 Under the age of 18c
Older LGBTI people LGBTI war veterans (USA)
Socioeconomic disadvantage or poverty High income settings
Disabilities
Migrants, immigrants, asylum seekers, refugees
Inclusion criteria (S2) Exclusion criteria
Acute care, community, hospitals, health promotion, surgeries, mental health services Occupational health
Health professionals including gynaecologist, obstetrician, GP, psychologist, psychiatrist, Lay workers
mental health practitioners, nurse, midwife, surgeons, paediatrician, endocrinologist
Human care, treatment, practice Animal care

a: Research focussing on MSM and WSW were excluded as this review focussed on sexual orientation/identities instead of sexual practices.
b: HIV/AIDS and other STIs were excluded due to being an already well-researched area and the resulting large and diverse literature
available.
c: Intersex research with participants under the age of 18 were included due to a peak in health service access during puberty and prior to
the age of 18.

discrimination law and the level of legal and social recognition problems and chronic fatigue syndrome,6 whereas gay and
varied significantly. Where LGBTI people did not have legal bisexual men showed a high incidence of long-term gastrointestinal
protection, they were more apprehensive when accessing problems, liver and kidney problems.6 Lesbian women had a higher
healthcare due to anticipated stigma;12,17 or LGBT people rate of polycystic ovaries compared to women in general (80 vs.
internalized stigma where they devalued themselves because of 32%)6 and both lesbian, gay and bisexual people showed weight
their gender identity or sexual orientation leading to significant discrepancies compared to the general population.23,25 Of LGB
barriers in accessing healthcare.17 groups, the general health of bisexual people was poorer compared
to lesbian and gay counterparts due to their minority status in both
communities.12
What is known about the health inequalities faced by LGB people are at a higher risk of developing certain types of
LGBTI people? cancer at a younger age.26 Gay and bisexual men are twice as
Health inequalities were experienced differently between LGBTI likely to report a diagnosis of anal cancer with those who are
groups and spanned both physical and mental health. LGB people HIV-positive being at the highest risk.3 Rates of anal cancer in gay
reported significantly worse physical health compared to the general and bisexual men are similar to the prevalence of cervical cancer in
population with gay men showing an increased incidence of long- general female populations prior to the introduction of cervical
term conditions that restricted their activities of daily living. screening programmes.3 This evidence supports the need for anal
Conditions included musculoskeletal problems, arthritis, spinal screening programmes geared towards gay and bisexual men. In
978 European Journal of Public Health

contrast there was no conclusive evidence of higher rates of breast associated with other factors such as lack of social support and dis-
cancer in lesbian and bisexual women.27 However, LGB people who crimination.33 LGBTI people were more likely to experience
survived cancer reported the need for psychological and emotional disabilities, and to be younger when doing so.34 LGBTI refugees
support to address their specific needs.28 There is a gap in high and asylum seekers were likely to be at risk of physical and mental
quality international research on both the cancer burden, general distress due to marginalization or abuse experienced in their country
health profile and care needs of trans and intersex people.3,29 of origin linked to their sexual orientation, gender identity or sex
In relation to mental health, significant inequalities exist with characteristics,35 though further research is needed to understand
LGBT people being twice to three times more likely to report fully and document the impact of intersectionality.
enduring psychological or emotional problems compared to the

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general population.30 Suicide attempts, suicidal ideation, What are the potential barriers faced by health
depression and anxiety disorders were 1.5 times higher for LGB professionals when providing care for LGBTI people
people compared to heterosexual peers with alcohol related
substance dependence over the previous 12 months being 1.5 times
and how can they be addressed?
more common in LGB people.30 Disparities related to mental Health professionals faced a range of challenges when caring for
distress were most pronounced for LGB people under the age of LGBTI people including heteronormativity where heterosexuality
35, and people over the age of 55.1 Intersex people also showed a is upheld as the status quo or gender normativity where the male-
raised incidence of suicide attempts at 19%, with 60% having female binary is retained as the norm.22,24 These norms were evident
considered suicide compared to 3% in mainstream populations.29 in practitioners own discomfort and unease whilst addressing the
Bisexual and trans people showed even greater disparities in mental gender identity, sexual orientation or sex characteristics in conver-
health compared to lesbian and gay counterparts, increasing the sations with LGBTI patients, combined with uncertainty about the
need for specialist mental health services and counselling use of language or terminology,28 and not knowing whether people
support.1,2,18 were LGBTI or not.36 Health professionals were not always aware of
Whilst accessing treatment and care, LGBTI people were more key health needs of LGBTI people nor specific health conditions, and
likely to report unfavourable experiences. General concerns were may unintentionally have been insensitive towards LGBTI people.37
around communication with health professionals and overall dissat- Case notes and multidisciplinary forms often failed to recognize the
isfaction with treatment and care provided.11,12,15,28 Trans people lives and partnerships of LGBTI people.14 Relevant documentation
frequently experienced negative interactions with health profes- like leaflets, marketing materials and processes for recording LGBTI
sionals at gender identity clinics, mental health services and patient information can help overcome barriers in communication
general health services. Where trans people attended gender where health professionals are encouraged to take account of gender
identity clinics, long waiting times for treatment was shown to and sexual diversity in clinical practice.11
negatively impact on their emotional wellbeing.15 When LGBTI people were recognized, or their lives and partner-
Like LGBT people, some intersex people experience isolation due ships were acknowledged, they were more likely to be open and
to stigma, discrimination or rejection from others.29 For some disclose their identity (‘come out’) or to share relevant health-
intersex people, experiences of adversity were linked to the related information.11 However some LGBT people had safety
medicalization of their bodies and being subjected to ‘normalising’ concerns or did not ‘come out’ due to their own need for privacy
surgery at a young age or where their bodies were surgically aligned and confidentiality.28 Consequently health professionals may not
to male or female sex characteristics.13,29 Dissatisfaction about have all the relevant information needed to make a full assessment
historic treatment was linked to health professionals not openly or to suggest appropriate treatment options.36 Where LGBT people
discussing information or failing to gain informed consent prior disclosed their gender identity or sexual orientation in health envir-
to surgical intervention on intersex minors.5 onments without negative consequences, their visibility correlated to
a better rapport with health professionals.17
Further barriers occurred where health professionals lacked ap-
What is known about the health inequalities of LGBTI propriate knowledge regarding the lives and related health needs of
people on vulnerable intersections? LGBTI people or where health professionals lacked the appropriate
In contemporary health and social care literature, it is well culturally specific skills necessary to meet their needs.11,12,14,29,31,35,36
understood that there is a strong relationship between the social As one of many examples, mixed methods research found only 41%
determinants of health inequalities and health outcomes.10 Various of older LGBT people in healthcare thought health professionals had
dimensions of social and cultural difference exist including gender, sufficient knowledge of LGBT issues whereas 59% thought health
sexual orientation, gender identity, gender expression, sex character- professionals did not have adequate knowledge.36 Global research
istics, age, ethnicity, race, social class and disability among others.12 reviewed was both clear and consistent in arguing for appropriate
Intersectionality can be understood as the intersections between training of both specialist and generic health professionals to address
these dimensions associated with social and cultural difference, key gaps in their knowledge and understanding when providing
that people experience.6,31 People carry certain markers of care,31,35,36,38 as well as informing LGBTI people of how to help
difference and for LGBTI people these dimensions can intersect to reduce the barriers they face when accessing health services.39
create multiple marginalizations such as, young trans people With increased knowledge, health professionals working in partner-
experiencing high rates of mental distress where their gender, ship with LGBTI people, can contribute to reducing health
sexuality, and age intersect compounding the discrimination they inequalities.
face at school.31 Indeed, the literature shows that living in rural
areas creates further health inequalities for LGBT people with Discussion
reduced access to services, particularly for trans people.17 Older
LGBTI people experienced both physical and mental health This review has established ‘what is known’ about the health
difficulties as they aged and became more dependent, however inequalities of LGBTI people and where change in practice or
social support seemed to act as a protective factor.32,34–40 further research is needed. By identifying these gaps, the findings
Conversely younger people appeared to be at risk of mental and recommendations can be of value for health policy makers,
distress and substance misuse in ways that affected their educational practitioners and researchers to help reduce these inequalities.
attainment.33 However, targeted resources such as peer support were Recommendations stemming from this review include the need to
shown to have positive outcomes.33 LGBTI people on lower incomes address high rates of anal cancer in gay and bisexual men, by
were at risk of mental distress and were more likely to smoke, introducing anal screening programmes to ensure early detection.3
 A review of LGBTI health and healthcare inequalities 979

As for mental health, there were disparities in the mental distress of key limitations should be noted. First, as a narrative synthesis,
bisexual and trans people compared to gay and lesbian counterparts, studies included were not assessed for quality and thus caution
resulting in the need for greater availability of specialist mental must be applied regarding interpretation and generalizability.
health services and counselling support for these groups.1,2,18,39 Second, some of the studies reported in this review combined
Specialist services are also required for intersex people with long- health profiles for lesbian and bisexual women, or gay and
term follow-up and improved access to counselling support.29 The bisexual men or LGB people without considering the health
review showed lack of substantive research on the general health inequalities of each individual group. In other words, our analysis
profile and cancer burden of trans and intersex people,3,29 with revealed that studies commonly collapsed sexual minorities into a
existing research often small in scale and limited in scope.13,20,29 single group. Although combining data can be useful for analytical

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Further large-scale research is needed to consider the general purposes, it may blur important issues specific to distinct groups
health and cancer burden of trans and intersex people and to and in some cases it was not possible to tease out such distinct issues.
explore their experiences of accessing healthcare. LGBTI people Future research designs should differentiate between LGBTI people
should be included in future research, policy initiatives and to ensure analysis can be conducted separately without presuming
decisions about healthcare delivery to represent their own health their issues are the same in ways that neglect intersectional
concerns and to ensure their views of how to improve services are differences.
reflected.6,11,31
Very little research specifically considers how more than one Supplementary data
factor intersect to influence the health outcomes of LGBTI people.
Further research is needed to understand fully and document the Supplementary data are available at EURPUB online.
potential impact of intersectionality. Where this kind of research did
exist, studies showed that living in rural areas, being on a low Acknowledgements
income,33 being an LGBTI refugee or asylum seeker,35 being
younger,31,33,34 or older32,36 and living with disabilities34 The information summarized in this review was prepared for the
compounded the health inequalities of LGBTI people. Minority European Commission. Findings were presented at the Healt4LGBTI
stress theory proposes that inequalities occur due to social, Conference on 1–2nd February 2018 at the European Committee of
cultural and political factors where LGBTI people may experience the Regions, Brussels. We are appreciative to the Health4LGBTI
discrimination associated with their minority status.19,25,28 In health network as well as members of the Health4LGBTI project scientific
settings where LGBTI people faced prejudice they were less likely to advisory board, Dr Rafik Taibjee, Dr Igor Toskin, Dr Kai Jonas,
‘come out’.11,28,36 Dennis van Der Veur, Odhrán Allen, Dr Thierry Troussier and Dr
Key but achievable changes are needed in healthcare to address the Petra De Sutter for their feedback on draft research reports that
barriers that prevent access to care.11,17,38,39 This is essential action in informed this paper.
line with European efforts to abolish discrimination on any grounds
and to uphold and promote human rights.7–9,16 Recognition of Funding
LGBTI rights continue to vary significantly across European
Member States.16 However structural change can be facilitated via Funded by the European Commission, Health and Food Safety
policy, research and in practice combined with training of health Directorate-General, Directorate C Health, Unit C4 Health deter-
professionals to improve their understanding of the lives, partner- minants (SANTE/2015/C4/035) ‘A pilot project related to reducing
ships and health concerns of LGBTI people.31,35,36,38 Inclusion of health inequalities experienced by LGBTI people’.
LGBTI health and healthcare is imperative for curricula at
universities and education centres where health professionals are Disclaimer
trained. Health professionals will benefit from increased
knowledge of historic events where ‘homosexuality’ was criminalized The information and views set out in this paper are those of the
or medicalized as a ‘sexual disorder’, or where current framings of authors and do not necessarily reflect the official position of
intersex variance as ‘disorders of sex development’ persist in systems the European Commission. The Commission does not guarantee
of classification such as the WHO International Classification of the accuracy of the data included in this paper. Neither the
Diseases (ICD-11) or the APA Diagnostic and Statistical Manual Commission nor any person acting on the Commission’s behalf
of Mental Disorders (DSM-V). An understanding of the may be held responsible for the use of information contained
marginalization of LGBTI people via these legal and medical therein.
frameworks may result in some avoiding disclosure in health Conflicts of interest: None declared.
settings acting as a barrier that prevents health professionals from
providing effective care.11,17 Training should show how sustaining
traditional heterosexual norms (heteronormativity) and binary
gender (gender normativity) may be in tension with the equal Key points
rights afforded to LGBTI people in European Member States.16  LGBTI people experience significant inequalities in terms of
With increased understanding of evolving diversity, practitioners their mental health, physical health, cancer burden and
can approach LGBTI people without judgement. Where health reducing these is a priority of the EU.
workers uphold professional values of inclusivity and respect in  Very little large-scale research has been conducted on the
open communication,31,35,36,38 LGBTI people may be more general heath profile of trans and intersex people highlight-
empowered to disclose their specific health concerns during consult- ing the need for further research.
ations.11,17 Health professionals could work in collaboration with  Norms that favour heterosexuality and gender binaries may
LGBTI people towards a collective goal of truly inclusive and lead to marginalization of LGBTI people creating barriers to
equally accessible services for all. effective healthcare.
 Health inequalities can be reduced by increasing the
knowledge and understanding of health professionals to
Limitations address these barriers in collaboration with LGBTI people
This review has made an important contribution to the field of themselves.
health inequalities experienced by LGBTI people. Nevertheless, two
980 European Journal of Public Health

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