Co‐producing knowledge of lesbian, gay, bisexual, trans and intersex (LGBTI) health‐care inequalities via rapid reviews of grey literature in 27 EU Member States

Abstract Background The health inequalities experienced by lesbian, gay, bisexual, trans and intersex (LGBTI) people are well documented with several reviews of global research summarizing key inequalities. These reviews also show how the health‐care needs of LGBTI people are often poorly understood whilst suggesting that targeted initiatives to reduce inequalities should involve LGBTI people. Objectives To determine what is known about the health‐care inequalities faced by LGBTI people? What are the barriers faced by LGBTI people whilst accessing health care, and health professionals when providing care? What examples of promising practice exist? Design Rapid reviews of grey literature were co‐produced with LGBTI people in 27 countries followed by a thematic analysis and synthesis across all data sets. The review included grey literature from each country that might not otherwise be accessible due to language barriers. Main results Rapid reviews showed that LGBTI people faced various inequalities and barriers whilst accessing health care. Where heterosexuality, binary gender and assumed male/female sex characteristics were upheld as the norm, and where LGBTI people differed from these norms, discrimination could result. In consultations where LGBTI people feared discrimination and did not disclose their LGBTI status, health professionals lacked the information required for appropriate assessments. Conclusion With greater understanding of sexual orientation (LGB people), gender identity (trans people) and sex characteristics (intersex people), combined with access to contemporary knowledge and training, health professionals can work in collaboration with researchers, policymakers and LGBTI people to develop systems that are better attuned to the needs of all service users.


| INTRODUC TI ON
The health inequalities of lesbian, gay, bisexual, trans and intersex (LGBTI) people are well documented in global research. 1 Several recent systematic reviews and narrative syntheses of research summarize these health inequalities. [1][2][3] Large-scale global reviews increasingly reflect how the health and health-care needs of LGBTI people are often poorly understood with evidence of a higher burden of certain conditions for both the physical health and mental health of LGBTI people compared with the general population. [1][2][3][4] Health inequalities are documented in a range of areas including increased rates of HIV and STIs in gay, bisexual and other men who have sex with men. 1 Also, reviews of studies on weight discrepancies in LGB people showed a higher risk of raised weight increasing sequentially with age. 5,6 LGB people reported experiencing worse physical health compared to the general population with gay men showing a higher burden of gastrointestinal problems, liver and kidney problems, 7 and lesbian women higher rates of polycystic ovaries compared with women in general. 7 Of LGB groups, the general health of bisexual people is poorer compared with heterosexual, lesbian and gay counterparts partly due to biphobia that exists in both heterosexual, lesbian and gay communities. 8 International research trends suggest that LGB people are at a higher risk of developing certain types of cancer commonly diagnosed at a younger age compared with the general population, 9,10 where gay and bisexual men are twice as likely to report a diagnosis of anal cancer with those who are HIV-positive being at the highest risk. 1 Those LGB people who survived cancer may benefit from additional support post-treatment to help them regain a sense of well-being. 9,11 A review of trans health needs indicated that across global health-care settings, trans people experienced significant health inequalities with higher rates of HIV and other STIs, mental distress, substance use and experiences of abuse (violence and discrimination) compared with non-trans or cisgender people. 2 In relation to mental health, research suggests that LGBT people are at higher risk of poor mental health compared to the general population with the incidence of suicidal ideation, anxiety and deliberate self-harm markedly raised. 2,4 Gay and bisexual men showed higher rates of recreational drug use, found to be most prevalent in those aged , and lower in those aged 45 and beyond. 4,5 Primary research exploring the health profile of intersex people is limited. 12,13 Studies undertaken often fail to account for the views of intersex people themselves, focusing instead on biomedical conditions and surgical outcomes. 12,14 Further research is needed in collaboration with intersex people to understand their experiences of accessing health care. 15 The same applies to research with trans and LGB groups, where much scope remains to include LGBTI people in research. Collaborative research with LGBTI people could inform future service delivery. 16

| Co-production
The above-mentioned global reviews are helpful as they provide an overview of health inequalities in terms of 'what is known' and where further research is needed; however, some studies are based on research that is done about LGBTI people instead of being undertaken in partnership with them. Research communities commonly regard primary research with robust quantitative designs as most rigorous, 17 or systematic reviews, meta-analyses or meta-syntheses as most useful in reflecting global trends for a specific field across data. 1 However, rich and more nuanced information can be contained in grey literature representing service user experiences and views.
Patient (or service user) and Public Involvement and Engagement (PPIE) in research and health service provision has grown significantly since confirmation of the World Health Organization Alma-Ata Declaration that marked the start of an international commitment to making health care equally accessible to all. 18 The principles underpinning PPIE include actively involving service users in research and 1 In this paper, we use the abbreviations LGBTI, LGBT and LGB consciously, to represent the discussion of different subsets within LGBTI in the reviewed literature.
Commission nor any person acting on the Commission's behalf may be held responsible for the use of information contained therein.
Main results: Rapid reviews showed that LGBTI people faced various inequalities and barriers whilst accessing health care. Where heterosexuality, binary gender and assumed male/female sex characteristics were upheld as the norm, and where LGBTI people differed from these norms, discrimination could result. In consultations where LGBTI people feared discrimination and did not disclose their LGBTI status, health professionals lacked the information required for appropriate assessments.
Conclusion: With greater understanding of sexual orientation (LGB people), gender identity (trans people) and sex characteristics (intersex people), combined with access to contemporary knowledge and training, health professionals can work in collaboration with researchers, policymakers and LGBTI people to develop systems that are better attuned to the needs of all service users.

K E Y W O R D S
co-production, Europe, health care, inequalities, intersex, LGBTI, public health, rapid review the organizations that conduct research, and involving service users in sharing knowledge of the research with the public. 19 This is essential action as global evidence mounts that LGBTI health inequalities do not necessarily stem from individual behaviour, genetic factors or lifestyle factors. Instead, some LGBTI people may encounter discrimination based on their sexual orientation, gender identity and sex characteristics. [20][21][22] A review of LGBTI health-care inequalities found when people access health care, they may experience minority stress associated with sexual orientation and gender identity, 5,23 heteronormativity (cultural and social norms that preference and prioritize heterosexuality), 24,25 victimization 26 and discrimination combined with the effects of stigma. [27][28][29] Furthermore, in global settings where LGBTI people were not legally protected against discrimination, they were more apprehensive when accessing health care due to anticipated or internalized stigma where they devalued themselves that may cause barriers in communication between LGBTI people and health professionals. 7,8,27 These factors such as discrimination and minority stress are linked to the causes of health inequalities; however, the causes are complex and often a combination of a range of individual as well as cultural, political and social factors. 5,7,13 Efforts to reduce LGBT health and healthcare inequalities is a social justice issue requiring targeted research, policy and practice intervention at multiple levels. 3,30 Consequently, research with LGBTI people and their engagement in health service delivery, research and policy is increasingly important as a collaborative effort to tackle inequalities. 3,16,31 LGBTI people should be included in decision making to represent their specific health concerns, and by helping to develop progressive services. 3,31,32 Along these lines, the principles of involvement and engagement were maintained in a European study entitled Health4LGBTI carried out by a Consortium of five EU partners appointed by the European Commission and funded by the European Parliament. The Consortium consisted of academic institutions, a Public Health body and key stakeholder associations.
The Health4LGBTI study was organized according to five thematic areas, each of which was managed according to a co-partnership arrangement involving a pairing of two of the Consortium partners. 13,20,[33][34][35] The LGBTI stakeholder association ILGA-Europe was a co-partner on all the research and communication activities to ensure that the overall Health4LGBTI study was designed and carried out with and by members of LGBTI communities (instead of about them). Furthermore, LGBT people were represented within the research teams of all the partners and in the project advisory board.
Co-production was understood as a considered process where LGBT people were actively and meaningfully involved in every aspect of the research: as co-applicants on the funding application; by Member States who played a key role in conducting the comprehensive scoping review (CSR; Figure 1).

| OBJEC TIVE S
The CSR was centred around the following core questions that were

| ME THODS
A critical realist framework was used to explore the research questions via a collaborative and accessible methodology. 36 The review followed a participatory approach where knowledge was co-pro-  Table 1).
The CSR included two tasks (see Figure 1): (a) a review of key European/international grey literature (policies, guidelines and legislation) and (b) rapid reviews of relevant grey literature from European Member States that may not be accessible due to language barriers. This paper presents findings of rapid reviews of relevant grey literature from 27 countries. A comprehensive overview of policy, guidelines and legislation is not included here due to the volume of data generated via the rapid reviews. 33 Partner organizations of ILGA-Europe identified LGBTI experts in each European Member State to conduct 'rapid-reviews' of relevant grey literature from their own countries.
These LGBTI contacts were involved in every stage from designing the template, identifying the literature and summarizing content for their country. The aim was to access grey literature that might not otherwise be accessible (eg non-English and/or not indexed in scientific databases), ensuring a good geographical coverage of the information and data collected by embracing different social and cultural contexts.

| Inclusion criteria
Inclusion of key EU/international grey literature in rapid reviews was determined by focusing on the core objectives. Literature that was pub-  Cyprus. Most reviews were completed in English; however, data presented via rapid reviews were the work of LGBTI contributors from specific countries, which meant some reviews translated summaries of texts only available in national languages. These reviews were translated to English. This is a key strength of this scoping review in being able to access literature that might otherwise be 'hidden'. The review processes utilized were not designed to evaluate the quality of grey literature but instead scope available literature. Data sets for each country varied in scope with reviews summarizing between 4

| Data extraction and synthesis
(Luxembourg) to a maximum of 40 (Germany) pieces of grey literature.
Each of the returned rapid reviews was edited for consistency and accessibility in terms of language and structure followed by a thematic analysis. 38,39 Themes were recorded in an Excel spreadsheet, coded and marked where they recurred for each country. Codes were reviewed and agreed between two analysts, and themes that did not have enough data to support them were discarded along with themes that did not address the research questions. 38 The process of editing, thematic analysis and coding was co-produced between the first two authors. The scientific review of literature undertaken before the comprehensive scoping review 13 provided the theoretical framework for the analysis.
The results that follow present examples of overarching themes that were developed to reflect the content across all 27 rapid-reviews.

| RE SULTS
Since LGBTI health inequalities were reported elsewhere in a review of global peer-reviewed literature, 3  Only the themes that recurred across a number of data sets were included (see Tables 3 and 4).

| Theme: Normativity
Heteronormativity and gender normativity were visible in most rapid LGBT people face heteronormaƟvity and gendernormaƟvity

ConversƟon therapy
LGBTI people are exposed to treatment or counselling to help them become heterosexual

Fear of coming out
Fear to disclose sexuality, fear of rejecƟon, fear of judgement, fear of negaƟve consequences that may affect treatment/care Experience individual or insƟtuƟonal transphobia/ biphobia/homophobia or discriminaƟon

Trans health needs
Trans peoples' lives and bodies are medicalised and doctors are gatekeepers to access care following diagnosis Trans people have limited access to specialist services for gender transiƟoning

MedicalisaƟon of intersex variance
Intersex variaƟons are pathologised and medicalised as DSD (disorders of sex development) Intersex people are subjected to correcƟve surgery at a young age without informed consent

ReproducƟve technology
Lesbian couples (or those in same-sex partnerships or those who are unmarried) are denied access / struggle to gain access to assisted reproducƟve technology

IntersecƟonality
No consideraƟon of intersecƟonality where discriminaƟon is based on more than one marker of difference i.e. sexuality and gender, age or ethnicity. LGBT asylum seekers are fearful of 'coming out' or acknowledging their sexuality

| Theme: 'Conversion therapy'
Data from the rapid reviews suggest that the widely condemned practice of 'conversion therapy' persists in some European Member Health insurance does not cover some or all transiƟon treatment for trans people and DSD (regarded as cosmeƟc) Use private provision rather than NHS.
x x x x x x

Lack of knowledge
Limited educaƟon and training for health professionals to address the specific health needs of LGBTI people

| Theme: Fear of coming out
Several MS rapid reviews reported on grey literature that showed how some LGBTI people feared 'coming out' to their peers, health professionals and in social settings due to potential negative conse-

| What are the potential barriers faced by health professionals when providing care for LGBTI people?
Rapid reviews identified barriers health professionals may face when providing care for LGBTI people such as lack of knowledge concerning the lives and health-care needs of LGBTI people; lack of awareness or consideration of the sexual orientation, gender identity or sex characteristics of LGBTI people who access health services; limitations around the prohibition of blood donation; or a lack of specialist mental health services and counselling services for LGBTI people.

| Theme: Lack of knowledge
All rapid reviews specifically drew attention to literature highlighting the seemingly limited education and training opportunities available for health professionals to address the specific health needs of  Even where the exclusion of MSM did not exist as a legal requirement, people may have been turned away by health professionals as gatekeepers to these services. Across the rapid reviews, data suggested that many LGBTI people anticipated negative consequences when disclosing their sexual orientation, gender identity or sex characteristics to health professionals. Moreover, it also seems that some health professionals have a limited awareness of equal rights and the protected nature of sexual orientation and gender identity in many European Union Member States.

| Theme: Lack of mental health services
Due to multiple layers of marginalization, many LGBTI people may experience discrimination and stigmatization. Consequently, the incidence of mental health problems can be much higher for this

| What examples of promising practice exist to address the specific health needs of LGBTI people in your country?
The

| D ISCUSS I ON
The results of the rapid reviews consistently demonstrated a range of health-care inequalities, barriers to accessing and providing care, and discrimination based on gender identity, gender expression, sexual orientation and sex characteristics for LGBTI people. Some LGBTI people feared negative consequences such as being treated as different or as 'other' whilst accessing (or attempting to access) health care. 11,40 Due to the effects of discrimination and stigma, research reported that specialist mental health or psychological support services for LGBTI people where they could make meaning of adversity were lacking. [2][3][4]11,12 Rapid reviews were consistent with wider academic literature in reporting that gay, bisexual and trans people can be deterred from accessing health care such as seeking HIV testing and treatment if they feared discrimination or encountering the stigmatizing attitudes of health professionals. 27 The reviews reported literature stating that LGBTI people were either prohibited from donating blood where they had engaged in same-sex sexual practices, or another example where they were signposted to conversion therapy as a treatment option to help 'cure' them. In relation to conversion therapy, health professionals' assumptions framing LGBT identities as 'disorders' were based on dated diagnoses that were removed from the psychiatric systems of diagnosis and classification (DSM and ICD) as part of the demedicalization of sexual orientation. 41 This lack in knowledge supports the need for education and training of health professionals widely reported in research to question normativity and promote more inclusive health-care practices for LGBT people. [1][2][3][4]24 Health professionals will benefit from further education and training to help them navigate their way through changing terminology and complex health-care systems.
For example, even though sexual orientation was demedicalized, the classification of gender dysphoria that frames trans people as gender non-conforming persists in the DSM-5. 42 Whilst these categories unnecessarily label trans people, the diagnosis acts as a gateway to hormonal treatment, surgery and the related medical technologies many trans people require to align their bodies and gender identity. 43 Similar restrictions based on biomedical diagnoses of intersex people apply. Intersex relates to a range of physical traits or variation that lie between binary ideals of male and female where many forms of intersex variance exist, whilst understanding sex as a spectrum rather than a binary category. 14,15,20  More research is needed to account for the views of intersex people themselves regarding their health and experiences of accessing health care. 3,12,15,44 Notwithstanding the value of and limitation associated with biomedical classification, the Yogyakarta Principles guide to human rights affirm binding international legal standards regarding LGBT people where 'Everyone has the right to the highest attainable standard of physical and mental health, without discrimination on the basis of sexual orientation or gender identity' (Principle 17). 45 Through changes in legislation, significant progress has been made towards achieving equality for LGBT people in Europe 21,22,46 and the UK. 47 Awareness of the need to assert the rights of LGBTI people is increasing with the knowledge of protection against discrimination based on sexual orientation (lesbian, gay, bisexual people), gender identity (trans people) and sex characteristics (intersex people). 3 As the struggle for recognition of LGBTI people's fundamental rights persists, LGBTI activists, NGOs, researchers and practitioners are working in collaboration to campaign for full recognition including legal recognition of gender, non-discrimination in the workplace, non-discrimination when accessing services provided by public-facing organizations, and freedom of expression. 46,47 Health inequalities can be better tackled where normativities in relation to gender, sexuality and sex characteristics are questioned.
Heteronormativity implies that people's gender and sex are by nature and align with opposite-sex attraction as the only conceivable way of being 'normal'. 24,40,48,49 Rapid reviews showed how healthcare inequalities occur in contexts of heteronormativity where heterosexuality is upheld as a key social and cultural norm. Broader research shows in health-care settings where LGBTI people access care, being heterosexual is often assumed as a given. 24,25 LGBTI people are marginalized due to heteronormative or gender norma- LGBTI people. 50,51 The actions of health professionals may be (un) intentionally insensitive towards LGBTI people. 25,40 When LGBTI people are overlooked due to assumed heterosexuality, cisgenderism (non-trans) and normative sex characteristics (intersex), the relationship between health providers and people who access care is adversely affected. In these instances, LGBTI people who access health care and other support services are less likely to be open and disclose their sexual orientation, gender identities or sex characteristics in the first few consultations, or they may be hesitant to share information relevant to their specific needs. 24 LGBTI people accessing HIV testing and consulting services where their confidentiality and anonymity were respected or gaining access to psychological services provided via peer-to-peer support mechanisms. The challenge for health professionals who work in collaboration with LGBTI people is to develop the structures for general and specialist health-care provision that are truly inclusive and equally accessible to all regardless of gender identity, sexual orientation or sex characteristics. Appropriate training for health professionals, co-facilitated by LGBTI people across all health systems, is an important step in this direction.

| LI M ITATI O N S
Data presented via rapid reviews were the work of LGBTI contributors from 27 countries which meant some reviews translated summaries of texts only available in national languages. Whilst this is a key strength of this scoping review in being able to access literature that might otherwise be 'hidden', it also means that the authors were unable to verify the appraisals of literature or accuracy of translations. The processes utilized in this rapid review were not designed to evaluate the quality of grey literature but instead scope available literature in each EU country.
The rapid-review protocol asked for LGBTI experts to differentiate (where possible) between L, G, B, T and I people when reporting on literature from their countries. However, in some cases it is unclear which group(s) the literature reported was referring to. Consequently, where this was unknown, the full acronym of LGBTI was used.

ACK N OWLED G EM ENTS
On behalf of the Health4LGBTI Consortium, we extend our sincere thanks to the rapid-review expert contributors in each European Member State for their assistance and support in undertaking the rapid reviews in their countries. Individual contributors are not named here to ensure their anonymity and confidentiality.
In addition, we extend our appreciation to Odhran Allen at GLEN

CO N FLI C T O F I NTE R E S T
None declared.

E TH I C A L A PPROVA L
Ethical approval for the CSR was not needed as the study did not collect any primary data. Other components of the study such as focus groups and training gained ethical approval in Poland and Italy as well as via the College Research Ethics committee (CREC) at the University of Brighton.

DATA ACC E S S I B I L I T Y
The data that support the findings of this study are available from the corresponding author upon reasonable request.

R E FE R E N C E S S U PP O RTI N G I N FO R M ATI O N
Additional supporting information may be found online in the Supporting Information section at the end of the article.