The Politics of LGBT+ Health Inequality: Conclusions from a UK Scoping Review

This scoping review of UK evidence aimed to describe what is known about Lesbian, Gay, Bisexual, and Trans (LGBT+) health inequalities in relation to cancer, mental health, and palliative care to inform research, policy and public health interventions. Using a scoping review methodology, we identified studies from database searches, citation tracking, and expert consultation. The in/exclusion criteria was based on the PICOS framework. The data were charted and then summarised to map the theoretical approaches and the main types of evidence and identify knowledge gaps. In total, 279 articles were screened and 83 were included in the final review. We found that there is limited UK research examining LGBT+ health inequality in cancer, mental health and palliative care. We would argue that this thin evidence base is partly due to national policy discussions of LGBT+ health inequality that are framed within a depoliticised ‘it’s getting better’ narrative, and an unwillingness to adequately acknowledge the unjust social and economic relations that produce LGBT+ health inequality. In addition, LGBT+ health inequality is depoliticised by existing public health explanatory theories, models and frameworks that exclude sexual orientation and gender diversity as dimensions of power that interlock with those of socio-economic, race and ethnicity. This is a barrier to developing public health interventions that can successfully tackle LGBT+ health inequality


Introduction
There is now a body of research evidence that demonstrates that lesbian, gay, bisexual, and trans (LGBT+) people experience significant health inequalities in terms of health outcomes, health care service provision and health risk factors in comparison to cis-heterosexual populations [1]. Recent research has highlighted how LGBT+ experiences of health and well-being require specific or specialised identity-centred interventions to better support LGBT+ health in a range of specialties [1][2][3][4][5][6]. Current research across multiple types of service provision has highlighted how LGBT+ people perceive current health or social care provision as in need of improvement in relation to their treatment and sexual and/or gender identity [7][8][9].
Increasingly, these inequities have been recognised by the UK Government and national health bodies (e.g., NHS England and Public Health England). In particular, policy attention on LGBT+ health was sparked by the 2017 Government Equalities Office survey of UK-based LGBT+ people [1]. This survey received more than 108,000 responses from LGBT+ people who highlighted the significant everyday experiences of discrimination that LGBT+ people live through [1]. One outcome from the survey was the UK Government 2018 LGBT Action Plan with a specific target of improving health policy and health care provision for LGBT+ people [1]. Since then, the UK Government Women and Equalities Committee launched an inquiry into LGBT+ health and social care and made policy recommendations based on their findings [10]. However, preliminary work to define this scoping

Study Selection
The PICOS framework was utilised to define the inclusion/exclusion criteria (see Table 3) which is recommended when time and resources are limited [21]. Two reviewers screened the titles and abstracts from the electronic databases and then applied the inclusion/exclusion criteria to the full-text papers. In the course of conducting the scoping review, two reviewers made additional decisions to exclude from the review medical case studies and treatment guidelines because they did not address population health concerns. The final included studies were collated in the Endnote reference management system. Two reviewers independently checked the inclusion and exclusion criteria against all studies found in the course of database searches, citation tracking, journal hand searching, and expert consultation.

Data charting and Summarising Results
All data were reported according to PRISMA guidelines. A scoping review does not synthesise results but rather present an overview of all material reviewed [20]. Data were charted to allow for a narrative review. Arksey and O'Malley [20] borrow the term 'charting' to refer to Ritchie and Spencer's [22] technique for synthesising and interpreting qualitative data by filtering, categorising and organising material according to key issues and themes.
In this scoping review, two reviewers designed a standardised data chart excel template that allowed for data to be both extracted from each full-text study, and to develop an overall narrative review. The data chart template contained the main study details (e.g., study population, aim, methodology, key results) but also included 'conceptual framework' and 'interpretation' categories. The characteristics for each full text article was charted by a single reviewer with a second reviewer regularly assessing the data charting process to resolve any conflicts. This process was used to develop an overall narrative that summarised the results in a way that was consistent with the scoping review research question and purpose [17].

Search Results
The search was conducted between February and March 2020. In total, 279 articles were screened and 83 studies were included in the final review (see Figure 1 for PRISMA flowchart and Appendix A for included studies and a data extraction chart). question and purpose [17].

Search Results
The search was conducted between February and March 2020. In total, 279 articles were screened and 83 studies were included in the final review (see Figure 1 for PRISMA flowchart and Appendix A for included studies and a data extraction chart).

Results Summary
In this section, we summarise the broad UK research trends in relation to understanding LGBT+ health inequalities in (a) cancer, (b) palliative care, and (c) mental health.

Results Summary
In this section, we summarise the broad UK research trends in relation to understanding LGBT+ health inequalities in (a) cancer, (b) palliative care, and (c) mental health.
The results from all studies indicated that LGBT+ people were more likely to have a negative experience or outcome when being diagnosed, receiving treatment, or in posttreatment in comparison to the cis-heterosexual population. The majority of authors acknowledged that LGBT+ people's poorer experience and outcomes were due to the absence of LGBT+-specific care and attention from health care providers. Qualitative studies highlighted a significant area of concern was that LGBT+ people struggle to 'come out' in a cancer treatment setting [39], and consequently not receiving culturally competent care [32,35,40,42,44,56]. Fish and Williamson's work [38] found, for example, that some LGB people hid their sexual identities during cancer care treatment and in support environments [38]. Some studies indicated heteronormative institutional practices that implicitly marginalised LGBT+ people, such as Doran's study, which demonstrated how gay men with prostate cancer were treated with heteronormative assumptions that did not meet their needs [26].
The absence of UK large-scale comparative data and epidemiological data was a deficiency in the research studies identified. The implications of this lack of data were underlined by expert consultants as a key problem in developing understandings of cancer prevalence and recovery rates in LGBT+ populations. It was suggested that including sexual identity and gender diversity characteristics in the cancer registry would enable the study of cancer prevalence and epidemiology in LGBT+ populations. Experts also raised issues regarding the underfunding of LGBT+ cancer scholarship and barriers, i.e., 'institutional homophobia' in attempting to access data, gain funding, and enact health care policies to better support LGBT+ cancer patients.
All 10 studies demonstrated that palliative care and bereavement considerations were different for LGBT+ older people. Almack et al.'s [57] study found, for example, that older LGBT+ people may have had to live closeted lives and therefore may not have their same-gender partners recognised after their deaths [57]. Ingham et al. [59] found that older LGB women may face complex barriers following the death of their partner due to persistent heterosexist and heteronormative attitudes in the UK [59]. Similar to research on cancer and LGBT+ populations, this small body of research suggests that culturally dominant norms surrounding cis-heteronormativity contributed to LGB people's poor experience of palliative care and bereavement support.
Palliative care research experts also emphasized the absence of large datasets as a barrier to developing evidence to improve palliative care and policy for LGBT+ populations. Furthermore, experts argued that palliative care more broadly was not on the national agenda of the current government.
A total of 22 of the studies examined young people's experiences of mental health and consistently reported an increased incidence of LGBT+ youth poor mental health compared to their cis-heterosexual counterparts. Studies in mental health focused on conditions including depression, eating disorders, anxiety, suicidality and self-esteem, with no research conducted into exploring rarer diagnosis such as schizophrenia or dissociative identity disorder for example.
The evidence base is more developed in LGBT+ mental health inequality in the UK. This is facilitated by the recent inclusion of measures of sexual orientation (less so gender diversity) on large-scale datasets, e.g., the Adult Psychiatric Morbidity Survey [78]. This has produced some robust evidence such as a pooled analysis of 12 UK population surveys that demonstrates adults who identified as lesbian/gay have higher prevalence of common mental disorders when compared to heterosexual adults [91]. Importantly, the evidence base includes longitudinal datasets such as the Millennium Cohort Study that enable the tracking of poor mental health over the life course of LGBT+ populations. Amos and colleagues' [75] study indicates that by age 10 years, depressive symptoms were higher in sexual minorities than in heterosexuals. Reflecting the greater availability of large-scale data, studies have been able to provide robust statistical analysis of the differences between identity groups particularly bisexual, trans, non-binary and gender non-conforming identities. In Colledge et al.'s study, for example, bisexual women were 37% more likely to have self-harmed compared to lesbians [79]. Rimes et al [88] found that female SAAB (sex assigned at birth) participants (aged 16-25) (binary and non-binary) were more likely to report a current mental health condition and history of self-harm than male SAAB participants (binary and non-binary).
The majority of papers utilised (implicitly) the minority stress theory [107] as a theoretical paradigm to explore the relationship between LGBT+ status and the increased risk of poor mental health. The minority stress theory is a psychological conceptual framework that is critiqued by some studies [108] as inadequate to explain the broader social and cultural norms that impact on LGBT+ people's mental health.

Discussion
This review of UK evidence aimed to describe what is known about LGBT+ health inequalities in relation to cancer, mental health, and palliative care to inform research, policy and public health interventions. The UK has a long tradition of research on health inequalities but until recently LGBT+ population groups were not included in public health research, policies and practice that attempt to tackle persistent health inequalities between population groups. Since the Equality Act 2010 [109], there has been a substantial increase in recognition that LGBT+ populations have a disproportionate health burden in comparison to cis-gendered heterosexual populations. This is evident in numerous health policies, e.g., Suicide Prevention Strategy [110], Transforming Children and Young People's Mental Health Provision: a Green Paper [111]. In addition, the Equality Act 2010 public sector duty has driven a concern within the health care sector to demonstrate that it is providing services and care equally regardless of sexual orientation (and, to lesser degree, gender identity). There is much greater appetite from the UK Government, policy makers, NHS England, health staff and Public Health England to address LGBT+ health inequality.
However, the findings from this scoping review suggest that the evidence base, on mental health, cancer and palliative care, is insufficient to address this nationally recognised health inequality. The current body of UK LGBT+ health inequality research is relatively small but there is clear evidence of health inequities between LGBT+ and cis-heterosexual populations. The research is strongest in terms of demonstrating the elevated rates of poor mental health in comparison to cis-heterosexual populations [91,110,112], reproductive and sexual health cancers, risk/transmission rates and barriers [113][114][115][116], and late diagnoses of cancer [2,117]. The evidence base for palliative care [4,7,8,63,64,[118][119][120][121] is very small. Across all three areas of this review, there is consistent evidence that a significant proportion of health care providers are not well trained in LGBT+ identities, and consequently misunderstand the needs of LGBT+ populations [9,122]. This is particularly acute for trans and/or non-binary people who encounter difficulties engaging with gender identity services and health providers, and experience considerable barriers to reproductive and sexual health services [5,108,114,123].
The majority of LGBT+ health research in the three areas homogenise LGBT+ identities by using a single identity category, 'LGBT'. This has the effect of obscuring health differences between identity categories. The notable exception is a small subset of LGBT+ mental health research where substantial population-based datasets are available for reliable statistical analysis of differences between identity categories. These studies have suggested that when compared to heterosexuals and people who identify as gay and/or lesbian, bisexual-identifying people experience more significant rates of suicidality, eating problems, self-harm, and addiction [79,112], and trans and/or non-binary people have significantly higher incidences of poor mental health and greater risk of suicide and self-harm [124]. Furthermore, little research examines the ways in which intersectional minoritised identities may mediate LGBT+ health inequality. There is a lack of exploration of race, ethnicity, faith, immigration status, social class, (dis)ability, aging, etc. This is a substantial omission in the evidence base to support public health interventions. The UK has decades of research that establishes the ways in which major social inequalities such as socio-economic status, gender and race/ethnicity are determinants of poor health. If LGBT+ health inequality is to be successfully addressed, then it is imperative that research consistently examines the intersectionality of LGBT+ health inequality.
The results of this review suggest three key recommendations for the development of research on mental health, cancer and palliative care that can inform public health interventions to tackle LGBT+ health inequality. Firstly, there is often an absence of large datasets, with representative samples and administrative datasets on which to base our understanding of the extent of health inequality. Examples include differential cancer prevalence rates, access to health services, and treatment outcomes. Without large-scale datasets it is difficult to generate research that convinces policy makers and health care providers of the scale of the inequality. LGBT+ mental health research 'weight' of evidence has gained impetus at a national government level as large datasets have started to include measures of sexual orientation and gender identity, e.g., the Millennium Cohort Study, the Avon Bristol Study, the British Cohort Study 2012, the Health Survey for England 2011, 2012 and 2013, the Longitudinal Study of Young People in England 2009/10 and Understanding Society 2011/12. These are still missing for cancer and palliative care.
Secondly, LGBT+ health inequality research has a tendency to 'fix' or essentialise identity. The impact of this is the homogenisation of the categories LGBT+, especially bisexuality and trans/non-binary. In most cases, research prioritises LGBT+ identity and ignores other interlocking systems of oppression/power relating to class, age, disability and race/ethnicity. Public health research and policy must work with a framework that has central the multiple experiences of inequality (race, gender class, etc.) that are mutually constitutive of health outcomes and experience for LGBT+ populations. It is crucial that if we want to address LGBT+ health inequality that we have reliable data on the ways in which health differs between LGBT+ people.
Thirdly, the majority of LGBT+ health inequality research is conducted within the dominant frame of clinical, biomedical and lifestyle risk factors. Far less research employs an alternative theory using social models of health inequality such as socio-political, psychosocial or socio-ecological. The biomedical and lifestyle theories are individualistic approaches that primarily focus on decontextualised individual-level pathology, biology, and behaviour. In contrast, more social theories posit that there are interconnecting and complex social, cultural, political, economic factors that shape health inequality [15]. Much of the research included within our scoping review acknowledged that heteronormativity or LGBT+ discrimination and stigma were partly to blame for limiting access to services or poor experience of services. Very little UK research attempted to explain the underlying social mechanisms that influence LGBT+ health inequality. McDermott et al.'s [124] paper examining the social determinants of LGBT+ youth mental health inequality is a rare example (see also [120]).
The dominance of the biomedical and lifestyle risk approach decontextualises LGBT+ health inequality and reduces the ways of addressing the problem to individual biological pathology and improving access to treatment and services. While clearly it is important to provide equity of access to health services and treatments, this does not, from a public health perspective, address the inequality between LGBT+ and cis-heterosexual populations. Why, for example, is there poorer mental health? Why are there low rates of cervical screening? The theories we use to understand LGBT+ health inequality impact on the questions we ask, the data we collect, our analysis, and eventually our ability to address LGBT+ health inequality at a population level [13]. The lack of alternative social theory leads to depoliticised descriptions of LGBT+ health inequality that do not recognise power and the unjust social relations that produce LGBT+ health inequities. This is a barrier to developing public health interventions that can successfully tackle LGBT+ health inequality.
The purpose of this review was to provide a tentative direction for LGBT+ health inequality research that would improve the ability of public health interventions to successfully reduce this inequality. A scoping review is a methodology that is used when there are few resources, to give an overview, and should not replace a more in-depth systematic review. Despite these methodological limitations, scoping reviews such as ours can be adaptable tools to direct future research that informs policy and practice. In our view, future research on LGBT+ health inequalities in mental health, cancer and palliative care needs to: (1) be resourced through large-scale datasets; (2) utilise theories/models that recognise the unequal social relations that produce health equality; (3) and pay attention to the health differences between LGBT+ populations.

Acknowledgments:
We would like to thank the LGBT+ Consortium, the National LGB&T Partnership, and Michael Brady (LGBT Health Advisor, NHS England) for their input and ideas relating to the development of this paper. With great thanks to the following experts who assisted in the production of this systematic review: Catherine Meads, Julie Fish, Katherine Johnson, Katherine Rimes, and Kathryn Almack. All authors have read and agreed to the published version of the manuscript.

Conflicts of Interest:
The authors declare no conflict of interest. • To complete a systematic review and meta-analysis to highlight how sexual minority people's self-esteem compares to heterosexual people

Appendix A
LGB people compared to heterosexual people Systematic review and meta-analysis Self-esteem is lower in sexual minority identified people when compared to heterosexual people Some evidence suggests that there may be even more differences for men and bisexual people, but this is not yet conclusive LGBQ+-specific discrimination prior to accessing services 33% of clients did not disclose their sexuality, and 42% did not discuss sexuality in treatment LGBQ+ people felt that service stigma, lack of sexuality disclosure, lack of sexuality discussion in treatment, lack of LGBQ+ awareness affected their treatment 52% felt that treatment could be improved Gabb et al., 2019 [65] • To see how LGBTQ+ young people could sustain or survive familial relationships 12 LGBTQ+ young people and 5 'family-like' participants Semi-structured interviews, emotion maps, and diaries Families have a significant impact on LGBTQ+ young people's lives and emotional landscapes Family practices can be paradoxical which need to be navigated by young people • To observe LGBTQ-specific and general factors associated with having current mental health problems, and to look at the use of mental health services, and suicide risk and self-harm 1948 LGBTQ university students (age 16-25) Survey analysis All four outcomes were associated particularly with female gender, sexual abuse, other abuse or violence, and being trans Other more minimally associated factors (i.e., associated with one or more of the outcomes) included being bisexual, thinking that they were LGBTQ under the age of 10, coming out before age 16 From the age of 10, depressive symptoms were more apparent in LGBTQ+ young people, and continued to increase with age to a larger extent LGBTQ+ people were more likely to report self-harm at ages 16 and 21 with no clear demonstration that this decreased with age • To identify the prevalence of mental disorder, substance misuse, suicide, suicidal ideation, and deliberate self-harm in LGB people LGB people receiving counselling Systematic review and meta-analysis LGB people at higher risk of mental disorder, suicidal ideation, substance misuse, and deliberate self-harm than heterosexual people There are some differences between identities identified in this paper (e.g., LB women particularly at risk of substance use disorders) Lewis, 2009 [101] • To identify any indicators or trends in relation to place, sexual minorities, and mental health LGBT people Meta-analysis There is a high prevalence of NSSI among trans people-particularly trans men-when compared to cis people Suicidality is higher amongst trans people than cis people • To explore how LGBT young people seek help and experience suicidality 29 LGBT young people (interviews) and 789 young people (surveys) Interviews and an online survey Participants only ask for help when they reach a crisis point as they normalise their distress Seeking help is more likely when connected to self-harm, suicidality or sexuality/gender based abuse The reluctance to seek help comes from negotiating norms and being unable to talk about emotions • To investigate self-esteem and depressive symptoms as mediators of increased rates of suicidal ideation or self-harm among sexual minority youth, and the roles of childhood gender nonconformity and sex as moderators of these relationships 4724 young people Survey data SMY were 3x more likely to report past year suicidal ideation or self-harm Lower self-esteem and increased depressive symptoms partly explain the increased risk for later suicidal ideation and self-harm in SMY Results showed that there were high rates (>50%) of a 12 month suicidal ideation prevalence and also (>45%) a willingness to enact a future suicide attempt Bisexual (and pansexual) reported high levels of IMV-related outcomes (for example internal entrapment or defeat) • To compare mental health, selfharm, and suicidality, and substance use, and victimisation experiences between non-binary and binary trans young adults 105 trans females, 210 trans males, 93 non-binary AMAB, 269 AFAB non-binary Online survey data AFAB were more likely to report self-harm and a current mental health condition than AMAB AFAB participants more likely to report sexual abuse Non-binary AMAB were less likely to report past suicide attempts and previous help seeking for depression/anxiety Binary participants reported lower life satisfaction than non-binary participants Mental health problems, self-harm, suicidality, alcohol use, and victimisation experiences all higher when compared to general population statistics Rimes et al., 2019 [90] • To investigate LGB related and other factors associated with suicide attempts, suicidal ideation, and future suicide risk

LGB young adults Survey
LGB stigma and discrimination were significantly associated with suicide attempts, ideation, and future suicide attempt likeliness Bisexuality, not feeling accepted where one lives, younger sexual minority identification, and younger coming out were also associated with suicidality Other associated factors included female gender, lower social support, anxiety/depression help seeking, abuse/violence, and sexual abuse.
Rimes et al., 2019 [89] • To investigate whether sexual minority patients have poorer treatment outcomes than heterosexual patients Patients attending Improving Access to Psychological Therapies (IAPT) services

Routine national data
Lesbian and bisexual women have higher final session severity for depression, anxiety, and functional impairment, and increased risk of not attaining reliable recovery Bisexual men had higher final session severity for depression, anxiety, and functioning and increased risk of not attaining reliable recovery when compared to heterosexual and gay men Gay and heterosexual men did not differ on treatment outcomes Racial minority LGB patients did not have significant outcomes compared to white LGB patients • To see how young people talk about self-harm 13 LGBT interviewees, 66 LGBT focus groups

Interviews and focus groups
Dichotomy between display for public and personal intense distress amongst LGBT people Self-harm can be private, but can be a way of reaching out Self-harm is complicated and multifaceted Scourfield et al., 2008 [74] • To explore cultural context of youth suicide • To explore connections between sexual identity and self-destructive behaviour 69 young people Interviews and focus groups LGBT young people employ resilience, ambivalence and self-destructive behaviour when faced with distress Practitioners should move to ecological approach to help LGBT young people Semlyen, J er al., 2016 [91] • To determine an estimate of the association between sexual orientation identity and poor mental health and well-being among adults from 12 population surveys in the UK, and to consider whether effects differed for specific subgroups of the population

94,818 participants of large-scale surveys Survey analysis
In the UK, LGB adults have higher prevalence of poor mental health and low well-being when compared to heterosexuals, particularly younger and older LGB adults. Sexual orientation identity should be measured routinely in all health studies and in administrative data in the UK in order to influence national and local policy development and service delivery. These results reiterate the need for local government, NHS providers and public health policy makers to consider how to address inequalities in mental health among these minority groups • To compare well-being, common mental disorder symptoms, suicidal ideation over a lifetime, alcohol and drug use amongst non-heterosexual and heterosexual individuals

adults Survey
Non-heterosexual orientation strongly associated with common mental disorder, lifetime suicidal ideation, harmful alcohol and drug use Inner city sample had poorer mental health overall compared with national sample-this discrepancy was larger for non-heterosexuals than heterosexuals Childhood and adult adversity substantially influence but do not account for sexual orientation related mental health disparities  High resolution anoscopy with intervention for high grade squamous intrapithetial lesions was offered to asymptomative HIV-positive MSM. Patients and HSILs were treated and follow-up HRA was performed after 6 months whilst patients with low-grade squamous intrapethelial lesions had a repeat HRA after 12 months AIN-3 is a significant risk factor for subsequent anal cancer, although the tumours detected in screened patients were small localised, and generally the outcomes were favourable Darwin and Campbell, 2009 [35] • To assess sexual minority women's opinions relating to cervical screening 34 sexual minority women Q sorts There is a need for affirmation of diversity within criteria for national screening programmes. There is a complexity of meanings around cervical screening This project raised awareness of unmet need in relation to LB women with breast cancer; this in itself was notable as their needs were previously assumed to be the same as those of their heterosexual counterparts. Subsequently, LB women were included in equality and diversity policy statements for the first time. The project also provided a number of different learning opportunities for cancer professionals to develop knowledge, attitudes and skills Fish and Anthony, 2005 [44] • To see whether risk perceptions, experiences of health care, and health seeking behaviour were correlated

lesbians Survey
While lesbians were less likely than lesbians in a similar U.S. study to report that their risk of cervical cancer was the same as that of heterosexual women, perceptions of risk were not correlated with participation in screening. We assumed that bad experiences of screening would act as a barrier to attendance; instead, good experiences were associated with the increased likelihood of attendance. These findings underscore the need for a pro-active agenda for lesbian health which addresses the need for culturally competent health care, the sharing of best practice amongst health care providers, and the creation of systemic institutional change to improve the care lesbians receive There is the 'awkward choreography around disclosure' opportunities and dilemmas for LGB patients, we describe 'making sense of sub-optimal care' which included instances of overt discrimination but was more frequently manifested through micro-aggressions and heteronormative systems and practices, and explore accounts of 'alienation from usual psychosocial cancer support' Fish et al., 2019 [39] • To explore conditions under which a sample of British LGB cancer patients revealed their sexual orientation in hospital settings to enable a more nuanced approach to understanding disclosure in this context 30 LGB patients with cancer Semi-structured interviews There are three themes as part of the analysis: authenticity as a driver for disclosure in cancer care; partners as a (potential) salutogenic resource; and creating safe, healing environments conducive to disclosure. The findings are reported and discussed in relation to three inter-related concepts from current salutogenesis theorising including a sense of coherence, generalised resistance resources and healing environments which can facilitate sexual orientation disclosure Fox et al., 2009 [55] • To determine whether imiquimod was more effective than placebo for the treatment of high-grade anal canal intraepithelial neoplasia (HG-ACIN) 64 HIV-positive MSM Double-blind, randomised placebo-controlled clinical trial. Sixty-four HIV-positive patients were randomised to self-application of imiquimod cream or matched placebo into the anal canal three times a week for 4 months. Response was assessed by cytology, high-resolution anoscopy and biopsy 2 months after therapy. All patients who failed to resolve were offered treatment with open-label imiquimod for a further 4 months This study demonstrates the effectiveness of imiquimod for the treatment of ACIN, and the benefit of prolonged or repeated treatments. This form of therapy is likely to be especially valuable for patients with widespread multifocal ACIN who are otherwise difficult to treat, and should be considered as an adjunct to ablative therapy • To explore the evidence base for the premise that women who are exclusively lesbian have a very low chance of developing cervical cancer Lesbians Literature review Case reports and prevalence studies show that HPV can be transmitted sexually between women. It is not known whether prevalence of HPV or cervical cancer differs between lesbians and heterosexual women. The evidence consistently shows that prevalence of non-attendance for cervical screening is much higher in lesbian than heterosexual women, which is linked to a belief that lesbians are less susceptible to cervical cancer and have less need for screening. Despite sharing most of the same risk factors as heterosexual women, lesbians are much less likely to undergo regular screening Heyworth, 2016 [28] • To conduct a prostate cancer awareness survey, the results of which would inform the development of new patient information 217 gay/bisexual men and trans women Survey Using the data from the survey and the available evidence base, it was agreed that four postcards should be produced, addressing four key areas: survivorship-and specifically issues around sexual function following treatment; the prevalence of prostate cancer in gay and bisexual men; taking care of your prostate-reducing cancer risk; communication Hulbert-Williams et al., 2017 [40] • To explore cancer experiences in LGB people 68,737 individuals (0.8% were lesbian, gay, or bisexual)

National Cancer Patient Experience Survey
There is a pattern of inequality, with less positive cancer experiences reported by lesbian, gay and (especially) bisexual respondents. Poor patient-professional communication and heteronormativity in the health care setting potentially explain many of the differences found. Social isolation is problematic for this group and warrants further exploration Karnon et al., 2008 [29] • Cost-utility analysis of screening for anal cancer in high-risk groups from a UK perspective MSM Cost utility analysis Reference case results showed screening is unlikely to be cost effective. Sensitivity analyses identified two important parameters: regression from low-grade anal intraepithelial neoplasia (AIN) and utility effects. Increased AIN regression rates resulted in a minimum incremental cost per QALY gained of £39 405, whereas a best case scenario reduced the ratio to £20 996. The three overarching constructs illustrated the magnified disruption to men's biographies, namely marginalisation, isolation and stigma-relating to men's sense of being "out of sync"; the burden of emotional and embodied vulnerabilities and the assault on identity, illustrating the multiple threats to men's work, sexual and social identities; shifting into different communities of practice-such as the shift from being part of a sexually active community to celibacy McConkey and Holborn, 2018 [32] • To explore the lived experience of gay men with prostate cancer 8 gay men treated for prostate cancer In-depth interviews Gay men with prostate cancer have unmet information and supportive care needs throughout their prostate cancer journey, especially related to the impact of sexual dysfunction and associated rehabilitation, negatively impacting their quality of life. Issues associated with heteronormativity, minority stress, and stigma may influence how gay men interact with the health service, or how they perceive the delivery of care. Health care education providers should update prostate cancer education programmes accordingly • This systematic review investigated all evidence on whether there is, or likely to be, higher rates of breast cancer in LB women Lesbians and bisexual women Systematic review Searches found 198 references. No incidence rates were found. Nine studies gave prevalence estimates -two showed higher, four showed no differences, one showed mixed results depending on definitions, one had no comparison group and one gave no sample size.
All studies were small with poor methodological and/or reporting quality. One incidence modelling study suggested a higher rate. Four risk modelling studies were found, one Rosner-Colditz and three Gail models. Three suggested higher and one lower rate in LB compared to heterosexual women. Six risk factor estimates suggested higher risk and one no difference between LB and heterosexual women Merriel et al., 2018 [48] • To explore and compare the knowledge and attitudes of UK General Practitioners and sexual health care professionals regarding HPV vaccination for YMSM (16)(17)(18)(19)(20)(21)(22)(23)(24) GPs and Sexual Health Care Practitioners Survey Twenty-two participants (20 SHCPs, p < 0.001) had vaccinated a YMSM patient against HPV. GPs lack of time (25/38, 65.79%) and SHCP staff availability (27/49, 55.10%) were the main reported factors preventing YMSM HPV vaccination. GPs were less likely than SHCPs to believe there was sufficient evidence for vaccinating YMSM (OR = 0.02, 95% CI = 0.01, 0.47); less likely to have skills to identify YMSM who may benefit from vaccination (OR = 0.03, 95% CI = 0.01, 0.15); and less confident recommending YMSM vaccination (OR = 0.01, 95% CI = 0.00, 0.01). GPs appear to have different knowledge, attitudes, and skills regarding YMSM HPV vaccination when compared to SHCPs  LGBT people wanted greater inclusivity, a reflection of diversity, validation, safety, and 'like-minded' people in accessing services. Those working in end of life care should be sensitive to understanding LGBT lives. Trans people had specific concerns around being misgendered after their deaths Almack, K 2018 [8] • To explore the end of life care experiences and care needs of older LGBT people aged 60+ LGBT+ people aged 60+ or LGBT people in a relationship with someone aged 60+ across the UK

Survey and interviews
Participants' networks presented a complex diversity and richness including families of origin and of choice. It is clear however that LGBT older adult's histories and pathways have ongoing profound influences on the means of social support available to individuals at the end of life • To identify and appraise the evidence of the bereavement experiences of lesbian, gay, bisexual, and/or trans* people who have lost a partner and develop an explanatory model of lesbian, gay, bisexual and/or trans partner bereavement LGBT people who have lost a partner Systematic review Studies described universal experiences of the pain of losing a partner; however, additional barriers and stressors were reported for lesbian, gay, bisexual and/or trans* people, including homophobia, failure to acknowledge the relationship, additional legal and financial issues and the 'shadow' of HIV or AIDS. A novel model was developed to explain how the experience for lesbian, gay, bisexual and/or trans* people is shaped by whether the relationship was disclosed and acknowledged in life and into bereavement and how this impacts upon needs and access to care Bristowe et al., 2018 [61] • To explore health care experiences of LGBT people facing advanced illness 40 LGBT people from across the UK facing advanced illness (cancer = 21, non-cancer = 16, and both cancer and non-cancer = 3)

Semi-structured interviews
Experiences of discrimination and exclusion in health care persist for LGBT people. Ten recommendations are made within this data Fenge, 2013 [58] • To consider the experience of loss and bereavement for lesbian and gay elders Bereaved lesbian and gay elders (4) and an agency that works with older LGBT people Interviews Issues include: undisclosed identities, lack of recognition of partnership, disenfranchised grief, and cultural competency within health and social care service workforce, and accessing appropriate bereavement services, and support from funeral homes Harding et al., 2012 [7] • To identify and appraise the existing evidence for the needs, experiences, and preferences for palliative and end-of-life care in lesbian, gay, bisexual and transgender (LGBT) populations 12 articles, primarily relating to cancer experience of gay and lesbian people

Systematic review
Existing evidence is explicit and indeed repetitive in highlighting the educational needs of health care professionals to explore sexual preferences, avoid heterosexist assumptions, and recognise the importance of partners in decision making. There is also a significant need to research LGBT experiences and refine services for patients and their caregivers • To explore experiences of samesex partner bereavement in women over the age of 60 8 women who had lost a same-sex partner Semi-structured interviews and an interpretative phenomenological analysis The findings indicate that in addition to the experiences of partner bereavement noted in research with heterosexual widows, older women who lose same-sex partners may face particular challenges, which can impact upon psychological well-being and adjustment to loss. These challenges appear to result from past and current homophobic and heterosexist attitudes within the UK culture. A range of interventions at individual, group, health service, and societal levels may be beneficial in improving the psychological well-being of older women who lose a same-sex partner Westwood, 2017 [60] • To explore the 'right to die' debate from the perspectives of older lesbians and gay men 60 older LGB individuals Semi-structured interviews Older lesbians and gay men are multiply disadvantaged (a) by an increased risk of feeling that life is not worth living due to affective inequalities (inadequate informal and formal social support) and (b) by a denial of access to the right to die both under such circumstances and/or if they wish to resist the normativities associated with a passive, medicalised death. There is a need to distinguish between a wish to die because of deficiencies in the care system and a wish to die in order to control how, when and where one's life ends. The analysis highlights the contextual contingencies of 'vulnerability' in relation to the right to die and interrogates the heterosexist and disciplinary reproductive normativities underpinning the notions of 'natural' deaths