Written by Fiona Myers, Allyson McCollam, Amy Woodhouse
Scottish Development Centre for Mental Health
ISBN 0 7559 4564 6
This document is also available in pdf format (156k)
The authors would like to thank the speakers and delegates who contributed to the Equal Minds conference held in Edinburgh in October 2003. Their knowledge and enthusiasm were the important catalysts for this report. Our thanks also to the small group of people who convened in June 2004 and who helped to maintain the momentum.
Fiona Myers, Allyson McCollam and Amy Woodhouse,
Scottish Development Centre for Mental Health.
Joint Ministerial Foreword
The Scottish Executive has a vision of an open, just and inclusive Scotland where respect and understanding are fostered and where everyone is encouraged and enabled to live, work and take part in society to their full potential, free from prejudice and discrimination.
Work on mental health issues and well-being is an important part of our wider work to promote equality. People with mental health issues do face discrimination - but they may also face it by virtue of their gender, language, age, social origin, ethnicity, other/multiple disability, religion or belief, or sexual orientation. We want to encourage greater understanding of how these issues relate, we want to open the debate about how services should respond, and we want to raise awareness amongst mental health practitioners and service users.
In October 2003, with financial support from the Scottish Executive's National Programme for Improving Mental Health & Well-being, the Scottish Development Centre for Mental Health held a major national conference on the theme of inequalities, equalities and mental health.
Material and discussions from the conference have been used to develop this extensive resource document. Equal Minds includes an overview of published literature. It identifies key issues and challenges in understanding and addressing discrimination and inequality in mental health. It will inform discussions on policy, planning and practice at a local and national level in Scotland, both in specialist mental health fields and in the areas of equality and inclusion.
We think it is a valuable resource and we both support this work and take joint ownership of the document in the hope that it does serve to influence debate. We hope it will be well-used by those in the NHS, local authorities and the voluntary sector, and that it will support the emerging Community Health Partnerships in tackling health inequalities at local level.
Lewis MacDonald MSP
Deputy Minister for Health & Community Care
|Malcolm Chisholm MSP|
Minister for Communities
Chapter One Background to the Working Paper
How does being a woman or a man, being young or old, or from an ethnic minority community affect mental health? How does poverty and deprivation affect well-being? What does having a mental health problem have on the chances of being discriminated against? These were questions that formed the basis for the Equal Minds conference held by the Scottish Development Centre for Mental Health ( SDC) in Edinburgh in October 2003.
The National Programme for Improving Mental Health and Well-Being (The National Programme), which financially supported the conference, subsequently commissioned the SDC to prepare a working paper with a view to developing the discussions held at the conference: bringing together further evidence of mental health inequality in Scotland and exploring the implications. This summary presents some of the 'headline points' from the working paper.
Although funded by the National Programme, the views expressed are those of the authors.
Working Paper Scope
From an overview of published and 'grey' literature the working paper brings together indicators of mental health inequality and describes the risk and resilience factors influencing population mental health and well-being, and the mental health and well-being of different social groups: women and men, people from black and minority ethnic communities, people who are lesbian, gay, bisexual and transgender ( LGBT), people with mental health problems and physical disabilities.
The presentations and discussions at the Equal Minds conference, together with a small 'roundtable' discussion with people with experience and knowledge in the fields of equalities, social inclusion and mental health, contributed to the evidence base and informed the analysis.
The Working Paper is not a Cochrane-type review ranking different types of research evidence, nor does it claim to cover the whole of a very extensive field. Instead the aim has been to identify from a broad overview of the material, key themes and issues, with a view to helping to contribute to discussions around the implications for policy, planning and practice.
What do we mean by mental health inequality?
- Melzer et al (2004, p.9) argue that inequality and inequity might occur in the distribution of:
- Mental illness or mental health problems
- Personal and social factors causing mental illness and mental health problems
- Personal and social factors that increase resistance to mental illness and mental health problems
- Personal and social factors that facilitate recovery
- Personal and social factors that handicap individuals with mental illness and mental health problems
- And/or access to services that help to prevent mental illness
- And/or access to services that limit morbidity in duration or severity of mental illness and mental health problems
- And/or access to services that diminish social disadvantage
- The important point is that the distribution of risk and resilience factors that can influence mental health and well-being is not random: some communities and people are exposed to greater risk than others.
- The experience of poverty and economic inequality are associated with poorer mental health and well-being.
- The experience of discrimination, prejudice and stigma on the basis of aspects of social identity, such as gender, ethnicity, sexual orientation, age, disability or religion or belief can both be detrimental to mental health and well-being, and increase the risk of being in poverty or socially excluded.
- For people with mental health problems the experience of discrimination, prejudice and stigma can have negative social and economic consequences.
Chapter Two The Policy and Legislative Context
The Scottish Executive's Equalities Strategy (2000) is based on the principle of 'mainstreaming'. This is seen as a way of ensuring that policy making is 'fully sensitive to the diverse needs and experiences of people'. To begin to work through the policy and practice implications of the different sources of mental health inequality the working paper both adopts and adapts this idea of mainstreaming. It is suggested that to achieve mentally healthy public policy and practice there is a need to:
- Mainstream mental health improvement goals in policies and practices aimed at achieving social justice and closing the opportunity gap (and in ways that take into account the unequal distribution of mental health risk factors across and within different social groups).
- Mainstream social justice/equalities goals within mental health policies and services.
To create mentally healthy public policy therefore means looking beyond mental health specific policies and activities to other areas of policy which directly or indirectly impact on the factors associated with mental health inequality. One way of trying to map this is to think of three policy 'layers'.
- At one level are 'global' or overarching policies which, in Scotland, establish the broader anti-poverty, social justice and inequalities policy agenda, for example, the Social Justice and Equalities strategies (Scottish Executive, 2002b; Scottish Executive, 2000).
- The next 'layer' of policies are those relating to specific areas but which contribute to these overarching goals, e.g. policies relating to community regeneration, housing, transport and health.
- The third layer comprises activities within specific policy areas. Within health, for example, are policies specifically aimed at health improvement and reducing health inequalities. The catalyst for mental health improvement is the National Programme for Mental Health and Well-Being (Scottish Executive, 2003a).
Vehicles for achieving cross-cutting objectives include Community Planning and Community Health Partnerships.
The legal frameworks supporting equalities and outlawing discrimination or abuses of human rights comprise:
- Legislation intended to protect civil and political rights, such as the Human Rights Act 1998. This enshrines the principles of the European Convention of Human Rights within UK law.
- Equalities and anti-discrimination legislation such as the Sex Discrimination Act 1978, Race Relations Act 1976 and Race Relations Amendment Act 2000, Disability Discrimination Act 1995 and Employment Equality Regulations covering sexual orientation and religion or belief.
- Legislation intended to protect the rights of vulnerable people such as the Mental Health (Scotland) Act 1984, its successor, the Mental Health (Care and Treatment) (Scotland) Act 2003 and the Adults with Incapacity (Scotland) Act 2000.
- Legislation intended to promote the well-being of citizens, for example the Local Government in Scotland Act 2003.
Chapter Three Evidence of Mental Health Inequality: Some Facts and Figures
The following indicates some of the evidence on mental health inequalities. Much of the material draws on UK, GB or English data. Where available, data specific to Scotland have been used.
Poverty and Mental Health
- Across the UK adults in the poorest one-fifth of the population are twice as likely to be at risk of developing mental illness as those on average incomes (Palmer et al, 2003).
- Poverty, unemployment and social isolation are associated with the first incidence and prevalence of schizophrenia. First, admission rates to specialist psychiatric care for people with schizophrenia are higher among those resident in deprived areas ( ISD).
- In Scotland, twice as many suicides occur among people from the most deprived areas (Blamey et al, 2002).
Women and Mental Health
- Mental health problems affect more women than men (Palmer et al, 2003).
- Women experience higher rates of depressive disorder than men. Depression and affective disorder are the second most common reasons for women consulting a GP in Scotland ( ISD).
- Studies have pointed to the link between poverty, inequality and depression among women (Belle and Doucet, 2003).
Men and Mental Health
- Suicide is the leading cause of death among young men in Scotland. The rate for young men aged 10-24 years is higher among those from deprived communities compared with those from affluent communities (Scottish Executive, 2003b).
- Men experience earlier onset of schizophrenia with poorer clinical outcomes (Piccinelli and Gomez Homen, 1997).
- Rates of alcohol and drugs misuse are higher among men than women ( ISD).
People from Black and Minority Ethnic Communities and Mental Health
- The rates of diagnosed psychotic disorder are higher among people from African-Caribbean communities, though the nature and degree of this difference is contested (Nazroo, 1997).
- Rates of suicide, self-harm and eating disorders are higher among South Asian girls and women (Wilson, 2001; Tidyman, 2004).
- In one community-based study African-Caribbean people had a 60% higher rate of depression than white people; and the rate for African-Caribbean men was twice that of white men (Nazroo, 1997).
Lesbian, Gay, Bisexual and Transgender People and Mental Health
- Studies have found higher rates of depression among gay men, lesbians, people who are bisexual or transgender than the general population. A study in Glasgow suggests that young LGBT people may be particularly vulnerable to depression and anxiety (Coia et al, 2002).
- International studies, as well as those conducted in Glasgow, Edinburgh and Northern Ireland all point to higher rates of suicidal thoughts and attempted suicide among young LGBT people. Attempted suicide and self-harming behaviour is also prevalent among adults.
- Studies in Glasgow and Northern Ireland of young LGBT people found high rates of eating disorders. Gay men and transgender people report higher rates of eating disorder than among the general population.
People with Mental Health Problems
- UK-wide, only 24% of adults with long-term mental health problems are in work - the lowest employment rate for any of the main groups of disabled people ( SEU, 2004).
- People with mental health problems are nearly three times more likely to be in debt; and one in four tenants with a mental health problem has serious rent arrears and is at risk of losing their home (Melzer et al, 2002).
- In one study of people with a current or past experience of mental distress, one-half had been abused or harassed in public. One quarter felt at risk of attack inside their own homes (Read and Baker, 1996).
Chapter Four What are the Factors which affect Population Mental Health and Well-Being?
Mental health is more than the absence of mental illness. According to the World Health Organization ( WHO) it is:
'the emotional and spiritual resilience which allows us to enjoy life and to survive pain, disappointment and sadness. It is a positive sense of well-being and an underlying belief in our own, and others' dignity and worth'.
Risk and resilience factors are those influences that have been found to be associated with positive or less positive mental health. It is important to bear in mind that no direct causal relationship can be assumed.
Protective factors include:
- An individual's psycho-social life and coping skills.
- Social support as a buffer against adverse life events.
- Access to resources and services which protect mental well-being.
Risk factors associated with poorer mental health and poorer outcomes for people with mental health problems include:
- The incidence or impact of negative life events and experiences for individuals.
- Social isolation and exclusion.
- The impact of deprivation and structural inequalities.
- Unemployment, or employment in an unsatisfactory or insecure job can have direct or indirect negative mental health consequences.
- For individuals, the experience of poverty and disadvantage creates feelings of hopelessness, anxiety and powerlessness which may impact on not only on mental health and well-being, but also on physical health.
- Those living in deprived communities tend to have lower self-esteem, are more likely to report feeling lonely and that life is not worth living and to have a lower sense of being in control over what happens in their life than those living in a more affluent area.
Structural inequality can lead to people feeling distressed and hopeless and to unfairness being construed as in some way of their own making. Living in conditions which are themselves detrimental to health can lead to unhealthy life styles - smoking, unhealthy diet - further compounding inequalities in chances of reasonable mental health and well-being (Labonte, 1998). Financial pressures are the most frequently cited causes of depression ( IMS and Mental Health Survey, in Bundy, 2001).
The effects of exclusion and disadvantage are deep seated and can be played out throughout the life cycle and across generations - leading to cumulative advantages and disadvantages in mental health outcomes.
Structural Inequality and Mental Health: Policy implications
Mental and Physical Health Promotion and Prevention
- Reducing structural barriers to mental health and promoting policies that protect mental well-being will benefit those who do and those who do not currently have mental health problems and the many people who move between periods of mental health and mental ill health (Friedli, 2002).
- Promotion of mental health and well-being and prevention of mental health problems as integral to improving physical health, including for people with chronic physical health problems.
- Promoting the physical health of people with severe mental illness.
Employment and Mental Health
There are strong arguments for focusing on mental health in areas of public policy that relate to employment and employability, on the grounds of public interest, economic gain and social benefits for individuals and communities.
Social Inclusion and Community Regeneration
Ensuring community regeneration initiatives consider not just physical re-development, but psycho-social factors, and seek to include the most excluded groups, including people with mental health problems.
This section has summarised the factors that are associated with protecting or putting at risk individual and population mental health and well-being. However, these resilience and risk factors can be differently distributed across different social groups, and with different implications. The following sections look at what the evidence suggests this means for women and men, people from black and minority ethnic communities, lesbian, gay, bisexual and transgender people and people with disabilities, including people with mental health problems.
Chapter Five Gender and Mental Health
Why is gender important?
There are at least four reasons why it is important to consider the implications of gender - the social roles expected of men and women - on mental health:
- There are clear and consistent differences in the patterns of mental health problems experienced by men and women.
- There are differences in the distribution between men and women of the risk factors associated with mental health problems.
- How men and women experience and respond to these factors are not necessarily the same.
- How men and women experience and respond to services and treatment are not necessarily the same.
Women and Mental Health: Risk factors
A number of risk factors have been associated with 'the mental health consequences of women's everyday life' (Williams et al, 1993, in Barnes et al, 2002).
Across the UK and in Scotland, women are more likely than men to be living in poverty. Linked with this women:
- May have a low income in jobs over which they may have limited autonomy and control.
- May have responsibility for managing household income and debt, within a context in which household income may not be equally shared ( EOC, 2003).
- May have limited autonomy over severe life events (Astbury and Cabral, 2000).
Social and reproductive roles
Women's social roles as primary carer for children and/or other dependants may:
- Restrict women's employment opportunities.
- Create 'role overload' (Piccinelli and Wilkinson, 2000).
As a result, women's poverty may impact on the mental health and well-being of children and contribute to cycles of deprivation ( SEU, 2004).
Violence and abuse
Women may be vulnerable to the experience of violence and abuse:
- In Scotland, in 90% of reported incidents of domestic abuse, where the information was recorded, the victim was female and the perpetrator male (Scottish Executive, 2003c).
- Girls may also be more vulnerable to childhood sexual abuse (Nelson, 2001).
- Women who are refugees or asylum seekers may have been victims of torture, including sexual assault and rape (Wilson, 1993, in Wilson, 2001).
Women in secure settings
Although not a risk factor, women in secure settings, whether secure in-patient settings or prisons, have often experienced multiple disadvantages. According to the most recent Inspection Report for Cornton Vale, 80% of prisoners within the prison have a history of mental illness, over 90% of admissions have addiction problems and over 60% have a history of being abused ( HMIP, 2004).
Multiple Identity: Multiple disadvantage
A number of studies describe the impact of social and economic discrimination for women from black and minority ethnic communities, and among women asylum seekers, women with disabilities, and young lesbian and bisexual women.
Women and Mental Health: Resilience factors
The WHO identifies three main factors protective against development of mental health problems, especially depression, in women (Astbury and Cabral, 2000):
- Access to material resources to enable choices to be made in the face of severe life events.
- Psychological support.
Women and Mental Health: Preventing and responding to risk
One recent literature review found no research that addressed issues around mental health promotion or prevention that took a gender perspective (Barnes et al, 2002).
One UK-based survey concluded that mental health services (Williams, 2002):
- Do not meet women's needs.
- Can replicate inequalities.
- Can be unsafe for women.
- Can be insensitive to the effects of gender and other social inequalities such as race, class and age.
Other studies appear to confirm these experiences. For example:
One study of asylum seekers and refugees found that women felt unable to discuss their health problems, particularly their mental health problems with a male doctor (Ferguson and Barclay, 2002).
Another study among black women in Bradford draws attention to the 'fear and hopelessness' they encounter when in contact with mental health services (Essian, 2003).
MIND research in England found that only eight out of 22 lesbians would feel 'safe' disclosing their sexuality 'mainstream' mental health services (Golding, 1997).
Men and Mental Health: Risk factors
Risk factors associated with men's mental health and well-being include:
- Men have higher levels of unemployment. Unemployment has been implicated as a risk factor for men.
- Homelessness and rooflessness is higher among men than women.
- Men have a shorter life expectancy and fewer years of healthy life expectancy than women. Prevalence rates for heart disease are higher for men. This has particular salience given the associations between poor physical and mental health.
Crime and violence: men as victims; men as perpetrators
- Men are more likely to commit criminal offences and engage in violent behaviour, but can also be the victims of abuse and violence, including childhood sexual abuse, largely, though not exclusively, perpetrated by other men.
- Notions of masculinity and appropriate male behaviour may act as a barrier to men expressing their feelings or admitting to experiencing emotional/psychological difficulties. This may be implicated in the higher rates of suicide among young men.
- The perceived breakdown in traditional gender roles may have left men uncertain of their role in significant relationships.
Multiple identity: Multiple disadvantage
Studies have suggested the sources of multiple disadvantage and discrimination for some groups, such as men from black and minority ethnic communities and gay, lesbian and transgender men.
Men and Mental Health: Resilience factors
It is even harder to identify specific 'resilience factors' for men than for other groups. However, marriage is believed to be a greater protective factor for men than for women.
Men and Mental Health: Preventing and responding to risk
The main issue that arises in terms of preventing or responding to risk is the need to consider the ways in which services, including mental health services are delivered to reach and be accessible to men. For example:
- Accessibility and flexibility of services in terms of time, location and ethos.
- Holistic in approach.
- Avoiding stereotypes of men as unresponsive and lacking in emotional intelligence: supporting men to express their feelings and aspirations.
Gender and Mental Health: Implications
Embedding consideration of differential mental health impacts on women and men into other policy domains
- Through 'global' policies relating to, for example, low pay, welfare benefits, child care, access to employment and community regeneration which may impact differentially on the mental health and well-being of women and of men.
- Through specific policies or initiatives which largely, if not exclusively address aspects of women's or men's experience, e.g. the domestic abuse strategy, men's health pilots.
Embedding consideration of gender impacts within the mental health service system
Ensuring that programmes and initiatives for improving mental health and well being are gender sensitive. For example consideration of:
- What mental health or well-being means for men and for women.
- Given the different employment patterns of men and of women, the implications for mental health at work, including job retention and return to work for women and for men who may have or be at risk of mental health problems.
- The gender sensitivity of mental health improvement programmes for children and young people.
- What recovery means for women and for men with mental health problems.
Ensuring that mental health services are gender sensitive
For example consideration of:
- The need for women-only/men-only services.
- Accessibility of services, including where and when clinics are held, the availability of child care, enabling people, as far as practicable/appropriate, a clinician/carer of the same sex.
- The mental health care needs of specific groups of men and women such as:
- Women from black and minority ethnic communities.
- Men from black and minority ethnic communities.
- Gay, bisexual or transgender men.
- Lesbian, bisexual or transgender women.
Chapter Six Ethnicity and Mental Health
Understanding the implications of ethnicity means acknowledging first, the impact on the mental health and well-being of people from black and minority ethnic communities of discrimination and victimisation and, second, the potential or actual institutional racism of services and systems, including mental health service systems.
What is also important to understand is the heterogeneity of those encompassed within the category 'black and minority ethnic communities'. The 2001 census indicates that the minority ethnic population' comprises just over 100,000 or 2% of the Scottish population. This, however, includes Indian, Pakistani, Bangladeshi, Chinese, other South Asian, Caribbean, African, Black Scottish or any other Black Background, Any Mixed Background and Any Other Background. In addition, are those who experience discrimination and disadvantage not just on the basis of ethnicity, but because of their status as refugees or asylum seekers, or who are gypsies or travellers. Another distinction is between identities based on 'visible' characteristics such as skin colour or 'invisible' dimensions such as religion or nationality, white Irish or European migrants, for example.
Within in each group there will be further divisions based, for example, on whether individuals were born in the UK or Scotland, or experienced migration
People from Black and Minority Ethnic Communities: Risk factors
Data on the position of people from black and minority ethnic communities indicate that greater proportions of people are at risk of poverty and social exclusion than the general population. 2001 census data for Scotland analysed by the Commission for Racial Equality, for example reveals that people from black and minority ethnic communities experience:
- Higher rates of unemployment than the white population.
- Lower levels of economic activity with a much greater reliance on one wage earner.
- Higher levels of self-employment and segregated employment.
Racism, discrimination, victimisation and violence
There is a large body of evidence that indicates the pervasive nature of racism, racist victimisation and discrimination for people from black and minority ethnic communities. These experiences have two dimensions: the experience of racism in everyday life
and the potential racism experienced through contact with services, including mental health services.
The stigma and discrimination experienced by white people with mental health problems are replicated for people from black and minority ethnic communities. Potentially at least, people with mental health problems from black and minority communities are at risk of experiencing double or triple jeopardy: discrimination based on ethnicity; and stigmatisation on the part of the majority and minority communities based on having a mental illness.
Studies in England suggest that there are higher levels of contact with criminal justice systems among people from African Caribbean communities (Mallet, 2004); higher admissions to psychiatric hospitals via the courts; and greater involvement of the police in hospital admission (Sainsbury Centre, 2002).
For asylum seekers and refugees there is both the impact of the past and the experience of the present to cope with.
For Gypsy/Travellers the life experiences may include 'feeling trapped in a site where
no-one would want to live' (Scottish Executive, 2001) or of being forcibly moved on (Save the Children, 2000).
Multiple identities: Multiple disadvantage
In terms of socio-economic conditions and social exclusion, role expectations, expression or presentation of distress, access, use and responsiveness of services, studies suggest different patterns for men and for women within and across black and minority ethnic communities (Nazroo, 1997; Fatunmbi and Lee; 1999; Bhardwaj 2001; Wilson, 2001; Essien, 2003; Mirza and Sheridan, 2003; Zappone, 2003; Gilbert et al, 2004). Age too may impact on both risk factors and outcomes.
Ethnicity and Mental Health: Resilience factors
A number of studies describe the strategies women in particular from black and minority ethnic communities draw upon. These include:
- Developing social networks, resources and support (Zappone, 2003; Wilson, 2001; Essien, 2003).
- 'Cultural strategies: constructing identities as survivors and "challengers for injustice" in opposition to others' negative constructions (Zappone, 2003).
- Developing 'self-healing strategies' or coping mechanisms (Essien, 2003).
- Obtaining support and comfort from spiritual beliefs and practices (Wilson, 2001).
Ethnicity and Mental Health: Preventing and responding to risk
Mental health improvement and promotion
The Cares of Life project, in Southwark, South London aims to build community capacity to assist early intervention and build partnerships between the black community and statutory and non-statutory agencies (Olajide, 2004). No other studies were identified in the course of the review looking specifically at the experience of people from black and minority ethnic communities of programmes aimed at improving/promoting mental health and well-being.
In Scotland the National Programme for Improving Mental Health and Well-Being has funded a development post within the National Resource Centre for Ethnic Minority Health ( NRCEMH), to develop capacity within Scotland.
Mental health services
A common theme across much of the documentation consulted was of the barriers to access appropriate and timely mental health services. Barriers identified include:
- Lack of awareness of different understandings of mental illness.
- Cultural insensitivity including toward religious or cultural beliefs.
- 'Colour-blind' approach.
- Direct or indirect racism - individual and institutional.
These barriers are experienced at each stage from primary to secondary and tertiary care.
Ethnicity and Mental Health: Implications
There are a number of drivers for change in Scotland that extend beyond, but include the mental health service system. For example:
- The Race Relations (Amendment) Act 2000 which places a statutory duty on public authorities to promote racial equality and prevent discrimination.
- The Scottish Executive Health Department strategy Fair for All: Working Towards Culturally Competent Services (Scottish Executive, 2002a); and the Diversity and Equality Strategy for NHSScotland.
- The principles of 'equality', 'diversity' and 'non-discrimination' embedded in the Mental Health (Care and Treatment) (Scotland) Act 2003.
To further developing a coherent approach toward the mental health and well-being of people from black and minority ethnic communities requires:
Embedding consideration of mental health impacts on people from black and minority ethnic communities into other policy domains
The socio-economic disadvantages experienced by people from black and ethnic communities, together with the experience of racism and discrimination, suggest that policies relating to community planning/regeneration, education and training, employment, housing, criminal justice, transport, rural development, etc. will have a significant and differential impact on the mental health and well-being of people from black and minority ethnic communities, including asylum seekers and refugees and gypsy/travellers.
Embedding equalities considerations within the mental health service system
- Ensuring that the activities initiated under the National Programme for Mental Health and Well-Being are culturally competent.
- Developing further capacity at primary, secondary and tertiary health care levels to provide appropriate, timely, culturally aware and competent services to meet mental health need.
- Developing culturally competent practice.
Chaper Seven Sexual Orientation and Mental Health
There is consistent evidence of higher/different rates of depression, anxiety, suicidal thoughts, self-harming behaviour, eating disorders and substance misuse among lesbian gay, bisexual and transgender ( LGBT) people. But, being lesbian, gay, bisexual or transgender is not per se a cause of mental distress, nor is it a mental health problem. Homosexuality was declassified as a mental illness by the American Psychiatric Association in 1973 and the World Health Organization in 1992. The significant factors are the social and economic disadvantages LGBT people experience as a result of homophobia, transphobia and heterosexism. 1 This can result in discrimination, bullying at school or in the workplace, harassment, violence (including domestic violence) and exclusion.
Given that approximately half a million of Scotland's population are lesbian, gay, bisexual or transgender (Inclusion Project, 2003), this raises significant issues for mental health improvement and mental health service delivery.
Sexual Orientation and Mental Health: Risk factors
Economic and social discrimination
Studies have shown that in comparison with heterosexual men and women, lesbian, gay and bisexual people report more frequent experiences of discrimination. Discrimination can occur at school, in the workplace, in access to services, including health and housing, and in the community at large.
Abuse, bullying, harassment and violence
Among both young and adult LGBT people, studies suggest the pervasive experience of abuse, harassment, bullying and violence related to their sexual orientation.
Homphobic bullying, abuse and violence occurs in the school, workplace and in the home - including domestic violence between same sex couples.
For young people in particular, the experience of discrimination, abuse and violence has significant implications for coming out, 2 and with it, for identity, self-esteem and mental health and well-being. For both younger people and adults the impacts may be felt in terms both of social isolation or lack of social connectedness, and social and economic exclusion and disadvantage.
Multiple identities: Multiple disadvantage
The impact of stress, stigma and homphobia may be compounded for LGBT people who are disabled, come from black or minority ethnic communities, or who are older (Cochran, 2001; McNair, et al, 2001).
The multiple impacts of sexual orientation and gender are flagged up in a Glasgow study which found that of the 51% of the sample who had experienced sexism, the great majority were women (John and Patrick, 1999).
Sexual Orientation and Mental Health: Resilience factors
Notwithstanding the risk factors, the point is made by Cochran (2001) that the majority of homosexual or bisexual respondents did not evidence any of the measured mental health disorders. Studies reveal, for example, the importance of family, a sense of social connectedness and social support to psychological well-being particularly among young LGBT people (Detrie, 2002; Hershberger and D'Augelli, 1995). However, more research is needed to identify the protective and resilience factors upon which LGBT people can draw.
Sexual Orientation and Mental Health: Preventing and responding to risk
Lumsdaine (2002) argues that there is a need to integrate the health concerns of LGBT people across all areas of health promotion activity, not just in relation to sexual health. This clearly has implications for mental health improvement strategies.
One London-based organisation, PACE, has drawn up a set of good practice guidelines for working with lesbian, gay and bisexual people in mental health services ( PACE website, www.pacehealth.org.uk/guidelines.html , accessed 18 Jan 04).
Two themes emerge from studies looking at access to health services, including mental health services:
- A reluctance by LGBT people to disclose their sexual orientation to health care professionals because of a fear of discrimination or negative response.
- The lived experience of discrimination and negative reaction following disclosure, including breaches of confidentiality.
As a result of actual or anticipated discrimination and homophobia, people may be reluctant to access services, or may delay seeking help. For people who do seek help discrimination, homophobia, or lack of awareness or sensitivity, may compound rather than ameliorate distress (Cochran, 2001; Carr, 2002; Carolan and Redmond, 2003).
Sexual Orientation and Mental Health: Implications
Embedding considerations of mental health impact on LGBT people into other policy domains
The experience of discrimination, homophobia and heterosexism has implications for the implementation of the broader anti-discrimination and equalities agenda. For example, strategies relating to discrimination in employment and education, including sex education, and housing. The scope of community safety initiatives and anti-bullying strategies in the workplace and school also have implications for the mental health and well-being of LGBT people.
Embedding consideration of inequalities within the mental health service system
A number of studies reinforce the need for a public health approach to include and address the specific health inequalities that arise from the homophobia, heterosexism and social exclusion to which LGBT people are exposed (McNair et al, 2001; Lumsdaine, 2002).
In relation to mental health service design and delivery, the evidence suggests the need to:
- Reflect upon the homophobia and heterosexism that LGBT people perceive or experience within mental health services.
- Enhance awareness of the experiences of LGBT people, and the forms of discrimination and social exclusion they may encounter.
- Consider the nature of a 'culturally competent' mental health service for LGBT people.
Chapter Eight Disability and Mental Health
According to recently published data just under one in five adults in Scotland have a disability and/or a long-term illness (Scottish Executive, 2004a). In terms of understanding mental health inequality and disability the focus is on three groups of people:
- People with mental health problems
- People with mental health problems and physical disabilities
- People with physical disabilities
Although the concept of disability is often associated with physical impairments, the Disability Discrimination Act (1995) includes both people with physical or mental impairments with substantial and long-term adverse affects. The legislation therefore provides important protections against discrimination toward people with a 'clinically well recognised' mental illness.
People with Mental Health Problems: Risk factors
People with mental health problems are at risk of experiencing serious socio-economic disadvantage and social exclusion. Mental health problems and exclusion can become mutually reinforcing: mental health problems can lead to unemployment, debt, homelessness, and a breakdown in social relationships, which can contribute to worsening mental and physical health ( SEU, 2004).
Discrimination and stigma
A fundamental source of socio-economic disadvantage, inequality and social isolation is the stigma and associated discrimination with which people with mental health problems have to deal on a day-to-day basis. A recent Mind study found that 84% of people with mental health problems have felt isolated compared to 29% of the general population (Mind, 2004). In the same survey nearly 60% of people with mental health problems felt that isolation was linked to discrimination on the grounds of mental health.
The Disability Discrimination Act prohibits discrimination against disabled people in relation both to recruitment and in the course of employment, yet the picture that emerges consistently from the research is of the barriers experienced by people with mental health problems in retaining and/or gaining access to employment (Robbie and Pressland, 2003). The inter-related barriers identified include:
- Individual: for example people may lack the confidence or skills to seek employment, or are concerned about the impact of employment on their mental health.
- Attitudinal: Consistently people with mental health problems report discrimination and stigma on the part of potential and actual employers and work colleagues.
- Structural: Both the financial disincentives built into the operation of the welfare benefits system and a lack of support services to enable people to remain in, or
re-enter employment act as further barriers.
In the provision of goods and services, studies have found people with mental health problems to be disadvantaged in terms of accessing insurance, welfare benefits and education, and to have experienced discrimination in housing allocation, and from GPs and other health care providers.
People with mental health problems are at risk of poorer physical health. Yet studies have shown that mental health service users may rarely be provided with health promotion information or offered physical health care checks in a primary care setting.
Multiple identities: Multiple disadvantage
The stigma and discrimination that attaches to mental illness can be compounded by other sources of discrimination and inequality, by, for example, women with mental health problems, people with mental health problems from black and minority ethnic communities, people with mental health problems and learning disabilities.
People with Mental Health Problems: Resilience factors
The resilience factors that enable people to recover from mental distress and to resist the disabling effects of discrimination and stigma are the same as for everyone else: self-determination, hope, confiding relationships, access to social networks, having meaningful activity and roles, financial security and feeling safe. This implies, however, not just individual reserves, but also support services which enable individual recovery, socially inclusive 'accepting communities' (Dunn, 1999) and a legal infrastructure which enables people to participate fully as citizens.
People with Mental Health Problems: Preventing and responding to risk
Tackling stigma and discrimination, supporting inclusion
In addition to the legal framework provided by the Disability Discrimination Act, a number of initiatives aim to address the stigma and discrimination experienced by people with mental health problems including:
- The development of the Scottish Recovery Network, funded by the National Programme.
- Funding by the National Programme of job retention pilot projects as part of the Healthy Working Lives Action Plan (Scottish Executive, 2004b).
- The Social Exclusion Unit Action Plan ( SEU, 2004) for England and Wales.
- The extension of Fair for All, the Scottish Executive Health Department's strategy for culturally competent health services, to other groups, including people with disabilities.
People with Mental Health Problems: Implications
Embedding mental health considerations into other policy domains
To redress the inequalities to which people who have experienced mental illness are at risk, however, extends beyond the domains of health and mental health. Closing the opportunity gap for this group of people implies, for example.
- Consideration of the impact of community regeneration or development on economic inclusion or exclusion of people with mental health problems.
- Access to, and retention of, employment.
- Access to education and training.
- Improving awareness among public and private sector employers and providers of goods and services of the rights of people with mental illness under the Disability Discrimination Act.
- Improving awareness among people with 'clinically recognised' mental health problems of their rights under the Disability Discrimination Act.
Embedding considerations of inequality within the mental health service system
There is a role for mental health improvement in the lives of people who have mental illness.
The other side of the coin is the role of mental health services in redressing inequalities. Mental health services (in partnership with other agencies) have a key role in closing the opportunity gap for people who experience mental illness.
Mental Health of People with Physical Disabilities
It was not possible within the scope of the working paper to address the mental health impact of the socio-economic disadvantage, discrimination and stigma that can be experienced by people with physical disabilities.
For people with both mental health problems and physical disabilities including sensory impairments, however, the few studies identified begin to suggest the discrimination and multiple exclusions they may experience.
A key finding and implication is the need for further research and analysis of the associations between physical disability and mental health inequalities.
Chapter Nine Discussion
The Scottish Executive Equality Strategy (2000a) draws attention to the different ways in which equalities is approached in policy terms including equal opportunities, social justice and diversity models.
Each of these approaches can be used to identify and tackle mental health inequality at different levels.
Level 1: At a population level a Social Justice approach identifies and targets the structural causes of poverty and injustice. Programmes to address child poverty, or educational attainment can improve economic and social life chances with implications for improved mental health and well-being across generations. It also implies a role for services, including mental health services, in helping to address and redress mental health inequality.
Level 2: At the level of social identities, an equalities perspective recognises the differential impacts on specific groups of social and economic inequalities and the need for policies, services and practices to acknowledge these structural inequalities.
Level 3: At an individual level, a diversity perspective recognises and values difference. This has implications for developing practices that include, for example, an understanding of the importance for the individual of their sexual orientation and/or their cultural identity, but also the impact of racism, or homophobia on mental health and on the articulation or expression of mental distress.
Areas for consideration
It is beyond the scope of the working paper to map out in detail the implications. However, possible starting points would include considering issues of principle, policy and practice. For example:
Understanding issues of identity
- Understanding differences and recognising areas of commonality across and within different social groups as they relate to mental heath inequality.
- Understanding the implications of multiple identity/multiple disadvantage on mental health and well-being.
Policies and principles
- Developing a framework of values and principles to assist in addressing mental health inequalities.
- Ensuring mental health is a key component of social justice strategies and work on reducing inequalities in health.
- Identifying priorities to tackle mental health inequalities.
- Giving greater focus within the mental health service system on the structural factors that contribute to inequalities.
- Enabling a practice environment that respects difference.
- Identifying core competencies for inclusive practice.
- Building partnerships across communities of knowledge and experience.
- Building on evidence based and values based practice.
A theme throughout the report, however, has been that responsibility for reducing mental health inequality includes, but extends beyond, mental health specific policies and practices to encompass the breadth of policies aimed at achieving social justice.
To achieve this requires action: at policy level across policy domains, as well as within mental health policy; operationally, across domains and within mental health specific initiatives; and at the level of practice. It requires both a population based social justice approach; an equalities perspective that recognises the different impacts for different social groups; and a diversity mind-set that recognises and respects individual difference and human rights. This is both the challenge and the imperative.
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Key to Abbreviations
People from black and minority ethnic communities
Commission for Racial Equality
Disability Discrimination Act 1995
Department of Health
Disability Rights Commission
Equal Opportunities Commission
Information and Statistics Division, NHS National Services Scotland
Lesbian, Gay, Bisexual and Transgender people
Scottish Development Centre for Mental Health
Social Exclusion Unit of the Office of the Deputy Prime Minister
World Health Organization
1 The following definitions of these terms are taken from, Inclusion Project (2003), Towards a Healthier LGBT Scotland,LGBT Health Scotland, Glasgow.
Homophobia: An irrational fear and dislike of lesbian, gay and bisexual people, which can lead to hatred resulting in verbal and physical attacks and abuse;
Transphobia: an irrational fear and dislike of Transgender people, which can lead to hatred resulting in verbal and physical attacks and abuse;
Heterosexism: The belief that heterosexuality is naturally superior to homosexuality or bisexuality. This belief justifies domination and the imposition of values and beliefs.
2 Coming out refers to LGBT people's ongoing experience of disclosing their sexuality (Inclusion Project Report, 2003)