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What can be learnt from the past 75 years of LGBTQ+ health care?

This year the theme of LGBT+ History Month was #UnderTheScope, which explored the achievements and milestones of queer people in relation to medicine and health care.

As this is a pertinent theme for The King’s Fund, I thought I would put ‘under the scope’ institutions that contribute systemically to the health and wellbeing of LGBTQ+ people in this country – largely, the NHS and government – highlighting significant milestones over the last 75 years that provide important context for where we are today. 

With people at the heart of this work, I have spoken to six LGBTQ+ individuals who range in age, ethnicity, sexuality, gender identity, neurodiversity and socio-economic status to share their lived experience of some of the issues we’ve focused on in the timeline so that we can begin to understand the real impact on patients. These were a combination of structured (written) and semi-structured (phone) interviews with people who I know in a professional capacity. I reached out to individuals who I knew had an experience related to their LGBTQ+ identity, and put an open call out to my network, ensuring there was a diversity of backgrounds. Those I spoke to shared concerns about how racism, Islamophobia, ableism, and other factors in addition to their sexuality and/or gender identity, played a part in their access to, and experience of, health and care. 

The end of the 19th century saw the advent of the concept of homosexuality as a pathological medical or psychological condition, which legitimised ‘treatments’ to change it. Because of this pathologisation, decisions about the queer community are often made by people who don’t have the lived experience of being LGBT+. This can lead to health care inequalities, and abusive and coercive ‘treatment’ such as conversion therapy. However, over the decades there have also been remarkable examples of allyship, resilience, progress and hope. 

It’s 1948. The NHS has been established. As our timeline begins, homosexuality is still illegal in the UK and men can be prosecuted, imprisoned and made to perform hard labour if found guilty.  

1951

Michael Dillon, the first person in the UK documented to have undergone gender-affirming care, operates on Roberta Cowell. She undergoes the first documented vaginoplasty in Britain and transitions from male to female

Reference
Overlooked No More: Roberta Cowell, Trans Trailblazer, Pilot and Auto Racer - The New York Times (nytimes.com)

1966

First gender identity clinic opens

Reference
Gender identity clinic (GIC) - Tavistock and Portman

1967

Sexual Offences Act decriminalises sexual acts between two men over the age of 21

Reference
Sexual Offences Act 1967 - UK Parliament

1968

Homosexuality is classified as a mental disorder by the World Health Organization (WHO)

Reference
When Homosexuality Stopped Being a Mental Disorder | Psychology Today

1969

The Stonewall riots in New York mobilise the LGBTQ+ community around the world

1972

2,000 people marched in the UK’s first Pride march

1981

First documented case of AIDS in the UK

Reference
Forty years since the first reported cases of HIV | Terrence Higgins Trust (tht.org.uk)

'Services at the time were quite fragmented. Mainly men, mainly adult, mainly white. You would find people who didn’t fit into that had to travel out of borough to access any sort of care. The reality of having HIV, the fear of being seen going into a clinic, was real.'

Listen to real stories

1987

AZT, medication used to prevent and treat HIV/AIDS, becomes available on prescription

Reference
The evolution of three decades of antiretroviral therapy: challenges, triumphs and the promise of the future - PMC (nih.gov)

'From day one I have had an exemplary service within the NHS. A 17-year-old boy goes into a VD clinic, never been in one before, gets this devastating result, and the first thing the doctor does is to hug me. Immediately fast-tracks me to a health adviser. Every time I go into the clinic, I’m in a really warm, comfortable, supportive space where I don’t feel judged. And that in itself is one of the key factors that enabled me to survive.'

1988

Section 28 is introduced, making it illegal for local authorities to ‘promote homosexuality’ or ‘pretended family relationships’. It bans councils from funding educational materials. It remains enforceable until 2003

Reference
Section 28: What was it and how did it affect LGBT+ people? - BBC Three

1992

Homosexuality is officially removed from the International Classification of Diseases by the WHO. Many LGBTQ+ people in the UK were (and are) subjected to conversion therapy because of the classification

References
When Homosexuality Stopped Being a Mental Disorder | Psychology Today
Alan Turing & the medical abuse of gay men | Peter Tatchell Foundation

'I was struggling with my gender identity and saw it as a mental illness. As changing gender seemed to be an impossible proposition, I sought help. I thought I was some sort of deviant. A psychiatrist confirmed it was a delusion, but that he could ‘cure’ me. It simply didn’t work. I felt I was beyond curing and would have to learn to live with my ‘perversion’ and suppress it. Over the following eight or nine years I became more and more depressed and attempted suicide. The positive impact was that it inspired me to study psychotherapy in order to understand my perceived madness. Conversion therapy simply doesn’t work.'

1994

Age of consent for sex between two men is lowered to 18

Reference
Gay rights 50 years on: 10 ways in which the UK has changed - BBC News

1998

The London Women's Clinic's first lesbian couple is treated by donor insemination

Reference
Shared motherhood IVF for lesbian couples is gaining acceptance in the UK • PET (progress.org.uk)

1999

The UK sees the first same-sex couple to father a child through surrogacy

Reference
Britain's first gay surrogate parents Barrie and Tony Drewitt-Barlow set for TV series | Maldon and Burnham Standard

2001

The age of consent for same-sex male intimacy is lowered to 16

Reference
Gay rights 50 years on: 10 ways in which the UK has changed - BBC News

2002

The Adoption and Children Act allows same-sex couples to adopt and foster a child

Reference
Unmarried and same-sex couples free to adopt | Children | The Guardian

2003

Employment Equality Regulations make it illegal to discriminate on the basis of sexuality in the workplace

Reference
2003: Freedom from discrimination and harassment at work (stonewall.org.uk)

2004

Civil Partnership Act allows same-sex couples to enter a marriage-like contract

The Gender Recognition Act allows trans people full legal recognition of their gender (with birth certificates only allowing male / female options)

References
Gay rights 50 years on: 10 ways in which the UK has changed - BBC News
https://www.sqa.org.uk/files_ccc/GenderRecognitionAct2004.pdf

2008 - 2009

Parliament votes to scrap the 'need for a father' requirement from the Human Fertilisation and Embryology Act. Same-sex couples are recognised as the legal parents of children conceived through donated sperm, eggs or embryos

 489 IVF cycles (1% of all cycles)  and 984 (25%) donor insemination treatments, involve a female partner.

References
Fertility treatment 2019: trends and figures | HFEA
Human Fertilisation and Embryology Act 2008 (legislation.gov.uk)

'We did IUI [intrauterine inseminations] first and then after a few attempts we had a miscarriage. After that we thought let’s do IVF and have embryos in the freezer to have some time to heal from that. We were lucky that we had the funds to make the decision on our own timeline. In the NHS route you need to go through something like six failed IUIs to be eligible for IVF.* IUI’s are so emotional – we only went through three, I can’t imagine going through six.'
*NB. Over 15% of ICBs are not in line with NICE guidelines and require 12 self-funded cycles of artificial insemination

2009

17% of mental health professionals are found to have offered conversion therapy. 35% of those referrals were said to have been referred by a GP and 40% of those were reportedly treated within the NHS

References
The response of mental health professionals to clients seeking help to change or redirect same-sex sexual orientation | BMC Psychiatry | Full Text (biomedcentral.com)

2010

Equality Act is introduced, adding protections for trans employees to the Employment Equality Regulations Act

Reference
Sexual Orientation and Gender Identity Discrimination at Work | CIPD

2014

Marriage (Same Sex Couples) Act comes into effect

Reference
Marriage (Same Sex Couples) Act 2013 (legislation.gov.uk)

2016

NHS England announced funding for a large-scale PrEP trial in England. PrEP is medication that reduces the risk of getting HIV

References
IMPACT trial | Prepster
NHS commissioning » PrEP trial updates (england.nhs.uk)

2017

National LGBT Survey

5% of respondents to the National LGBT Survey said they had been offered conversion therapy to ‘cure’ them of being LGBT. Trans respondents specifically reported 8%.

Reference
UK conversion therapy ban to include trans people - BBC News

2018

Consultation on the Gender Recognition Act

In July 2018 the government launched the National LGBT Action Plan to improve the way that public services work for LGBT people

NHS-funded IVF at 39% for heterosexual couples, and 14% for women in relationships with other women

52% of LGBT people said they’ve experienced depression in the last year and 13% said they have attempted to take their own life

References
Lesbian couple challenge NHS over 'discriminatory' fertility policy - BBC News
LGBT in Britain - Health (2018) (stonewall.org.uk)

2019

2,435 IVF cycles (4% of all cycles, and 2,514 donor insemination treatments (44%), involve a female partner – accounting for the largest proportion of DI treatments.

A British lesbian couple become the first in the world to participate in ‘shared motherhood’ where the egg is incubated in one womb and then transferred into the other

WHO announces declassification of transness as a ‘mental disorder’ with the publication of ICD-11 

References
Fertility treatment 2019: trends and figures | HFEA
UK lesbian couple welcome world's first two-womb baby | Newshub
Transgender no longer recognised as 'disorder' by WHO - BBC News

2020

PrEP is now available on the NHS for anyone over the age of 16 who is at high risk of HIV infection

Reference
PrEP: Preventative HIV drug available in England from April - BBC News

Sexual health clinics remain largely positive and inclusive spaces for the LGBTQ+ community:

'I went there when I was 19. It was so non-judgemental and they really helped to educate me.'

2021

A legal case is launched against NHS Frimley Clinical Commissioning Group for discrimination of access to funding for fertility treatment for a same-sex couple

The ban preventing men who have had sex with other men from donating blood is lifted (a relic of the AIDS crisis)

Reference
Same-Sex Couple Issue JR Against “Discriminatory” IVF Policy | Leigh Day

2022-2023

Government announces that it is committed to removing barriers to IVF for same-sex female couples

ICD-11 published, officially declassifying trans as a mental disorder

References
IVF law change to benefit couples with fertility issues - GOV.UK (www.gov.uk)
Government pledges to end IVF policies which discriminate against same-sex female couples - BPAS Campaigns (bpas-campaigns.org)
First Women's Health Strategy for England to tackle gender health gap - GOV.UK (www.gov.uk)
ICD-11 Implementation (who.int)

'There’s a misconception, even among health care professionals, that in order to get a referral [for gender affirming care] you have to have a mental assessment, which is no longer true. My first doctor was rude and unsympathetic, and misgendered me multiple times. She said, “what – I can just call them up and say ‘this woman wants to be referred?’'

2024 – where are we now? 

Figures on access to services show that many in the LGBTQ community still face challenges seeking care and support. 

7,500 children and young people with gender incongruence / gender-related distress are waiting for help from the NHS (the Gender Identity Development Service at London Tavistock and Portman NHS Foundation Trust – the only gender clinic in England and Wales supporting children shut down this year. The two hubs set to replace it are currently establishing their services and focusing on the transfer of Tavistock patients so it is difficult to give an estimation of waiting times; patients will be transferred across to new regional centres when appointments become available). The publication of the Cass Review in April shows that a lack of evidence is letting down these young people. In addition, more than 26,000 adults are waiting for a first appointment with an adult gender identity clinic (23,561 have been waiting more than the 18 week target), conversion therapy is still legal in the UK (despite a commitment to ban it in 2018), there has been no substantial reform of the Gender Recognition Act (2004), and over 90% of integrated care boards are falling short of the Women’s Health Strategy target regarding fertility treatment and access for same-sex couples. 

'Luckily it only took me two GPs to get a referral to the gender identity clinic, because I know a lot of people that have been refused. They said the processing time was six months, and once it’s been processed it’s going to be three years. Hearing the times was really upsetting. There was a group therapy service that CliniQ provided. 

I also registered at 56 Dean Street clinic where they were taking on new clients to trial TransPlus – a service commissioned by NHS England similar to the GIC. 

It was about two years of waiting before I received actual gender affirming care provided by the NHS. But I was very lucky. I know so many people that it wasn’t accessible for. Also, because I do pass as cis for most people, that meant that I was believed by health care professionals more than people who don’t.' 

As we can see from the timeline, legislation doesn’t exist in a vacuum – it directly impacts people’s lives, health and wellbeing. In the last in-depth survey into LGBT health in Britain, carried out in 2018, 52% of LGBT+ people said they had experienced depression, and almost 50% of trans people and over 30% of LGB people had thought about taking their own life: 

'I was in hospital last year because I attempted suicide. I think a lot of it was other traumas, but I was thinking if I had been straight would it have ever got that bad? I just feel like it added something completely on top of it that made it too much – a little bit too hard.' 

Impact

LGBTQ+ people and families have always existed, but how the health care sector treats LGBTQ+ individuals is intrinsically linked to our survival as a community, and how society views us.  

Pathologising sexuality and gender identity led to the creation of laws against us and dreadful treatment of LGBTQ+ individuals. However, when health care treats LGBTQ+ patients equally, amazing things can happen. Consider the 1992 declassification of homosexuality as a mental disorder; the subsequent changes in the law over the next decade were hugely positive for the queer community. We can only hope that the declassification of transness as a mental disorder in recent years will have the same impact. Similarly, same-sex fertility treatments by private clinics were a precursor to legal changes in how same-sex couples are regarded as parents. 

Though the issues discussed in this timeline mainly affect and have been campaigned for by the LGBTQ+ community, they have had much wider social significance. Campaigning for access to fertility treatment and funding, and surrogacy reform, has not only helped queer couples but single people looking to birth a child or adopt. Access to AZT and PrEP doesn’t just benefit gay men but other communities that are disproportionately affected by HIV and AIDS, such as Black, Asian, and minority ethnic / Global Majority individuals. Progress isn’t always linear and we can’t be complacent in our pursuit of equality.