The UK government’s leading body for public health this week launched a new framework for improving the health of gay, bisexual and other men who have sex with men (MSM). Notably the document considers HIV and sexual health alongside other areas in which MSM have poorer health than the general population – mental health and the use of alcohol, drugs and tobacco. Public Health England also consider that a focus on individual behaviour is insufficient, but that the structural determinants of poor health need to be addressed too.
Public Health England (PHE) have identified research showing that men who have sex with men are twice as likely to be depressed or anxious as other men, are twice as likely to be dependent on alcohol as other men, are more likely to smoke, have higher rates of cardiovascular disease, asthma and diabetes and are less likely to seek help from health and social care services. Few men reveal their sexual identity to those providing care.
PHE suggest that these health inequalities are shaped by a range of factors including families and social networks, schools, workplaces, faith organisations, media, legislation and the wider cultural and social context in which men grow, live and age.
The document outlines three specific objectives:
- To reduce the number of newly acquired HIV infections in MSM.
- To close the gap in smoking prevalence between MSM and the general male population (currently 20% in heterosexual men, 25% in gay men, and 26% in bisexual men).
- To decrease the proportion of MSM reporting use of harmful illicit substances, including a reduction in the proportion reporting ‘chemsex’ or steroid abuse. (At present, 4% of heterosexual men use class A drugs, compared to 12% of MSM).
One reason these objectives can be set is that relevant data are available, with national surveys recording information on participants’ sexual orientation. For many other issues, no such robust data exist. It has therefore been impossible to set measurable objectives in relation to homophobic bullying in schools, self-reported mental health or heavy drinking.
The document takes a “life course” approach, in other words considering how a person’s health needs vary at different stages in his life. For example, whether a teenager feels safe and supported as he develops his sexual identity is likely to have a long-term impact on his behaviour and health. Older men may experience social isolation and have particular needs for appropriate health and social care.
The framework points to a more holistic approach to reducing HIV infections, with the interconnected problems of mental health, substance use and sexual health being considered together. Moreover it suggests the value of interventions which could address the wider determinants of health inequalities. This could include changes to the provision of sex and relationships education in schools, attempts to tackle discrimination based on sexual orientation, or programmes to promote social networks and social capital in MSM.
But while the document is called an “action plan”, it makes few clear recommendations for how things should change. It does describe a series of actions that Public Health England will take, but frequently change needs to occur elsewhere. Apart from the Department for Education and other government departments where concerns about health are not the top priority, many decisions about health are made at a local level, by local authorities and clinical commissioning groups. PHE can attempt to influence these bodies, but cannot impose its will.
Moreover in the current climate of ever-diminishing budgets and the under-funding of HIV prevention work, it remains to be seen whether the ambitions for more holistic and sophisticated programmes for men who have sex with men will be realised.
Professor Kevin Fenton, Director of Health and Wellbeing at Public Health England said: “Despite vast improvements in social acceptance over the years, lesbian, gay, bisexual and trans people continue to face discrimination. As a result, this community faces barriers in accessing health services, and remain disproportionately burdened with ill-health. This structured programme of action will work with and support the public health system, private and third sector organisations to actively respond to the needs of these communities locally.”