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So um Doctor Report Makinson is a research fellow in the NIH our Applied Research Collaboration, Greater Manchester at the University of Manchester. Her research uses large data sets to identify and understand socio demographic health inequalities. Current projects include investigations of inequalities in vaccine update between socio economic and ethnic groups and inequalities in mental health outcomes amongst the L G B T Q plus community. Before joining the University of Manchester Ruth, worked a biomedical research in Cambridge and New York are studying for a master's in public Health at the London Science of Hygiene and tropical medicine. So, should we give the ground records the roof? All right. Thanks for invitation. It's, it's great to see you. You're welcome to today. So yes. So the organizer suggested that I just give you a bit of an overview of my career and my kind of journey and research so far just to give you a sense of kind of where I'm coming from and the kind of stuff that I've been doing. So I've been really lucky and my career is taking quite a lot of interesting places around the world. We started also right here. So I came to Manchester University to do undergraduate biochemistry. And as part of that course, uh there was an opportunity that came up to move to Florida for a year and work in one of the research lads at the Mayo Clinic Hospital. And that was an incredibly opportunity. It was kind of cushy because we got paid for a year. But it was also just like a really great chance to get some hands on lab research experience. And it really opened my mind that kind of the possibility of a career and research. It was perhaps a bit naive, but it wasn't really something that I knew existed as a kind of a viable career option. So from there, when I came back to Manchester for my final year, I decided to apply for phd S because if you want to be a research that's often a good route to go. So it's an extra degree after you've done your undergraduate. And it's kind of very research focused. So it's a bit more like having a job, it's very much on the job kind of learning. So I work in a lab but with researching viruses and immune responses from that, um it was around 2014, which you might remember is when um the West African Ebola outbreak occurred. So this was the biggest outbreak that had ever happened and it really spiraled out of control and became a full epidemic and, and several countries in West Africa were really, really hard hit. So they kind of put out various requests for international help to try and bring the epidemic under control. So as part of that, they needed scientists who had experience working with viruses to come out and help set up diagnostic labs. So I volunteered to go out Cirincione and I was gonna team in Makeni and we helped establish a kind of temporary lab that was then we ran kind of blood test to diagnose Ebola and also help train up local staff to try and build capacity for local test, right. So from there, the next thing I did, I applied for a fellowship which allowed me to move to New York and I worked in one of the research adds at Mount Sinai Hospital. Um So again, I was doing kind of virus research and working on viruses kind of with academic and pandemic potential. But I think as I was there, I was really enjoying the lab work that I was doing and things, but also just kind of I think my experiences in Sierra Leone and then also in New York, I was kind of reflecting more and more on kind of what does shape health, what is the most important thing. And I think, you know, as much as biomedical advances are important, there's so much in terms of the social world that we all live in and kind of the social opportunities each of us have that shapes our health. And I think I gradually just started to be more interested in that side of research and that side of kind of what, what shapes our health and our health outcomes and access to healthcare. So from there, I then moved back to the UK and I spent a year at the London School of Hygiene and tropical Medicine study in public health. And then I moved back to Manchester and I'm now working again at the university as a researcher in public health and health economics. So what I do now is I'm out of the lab and I use kind of big data sets and do kind of statistical analysis to try and understand what is it that causes and drives and explains these big health inequalities between different social and demographic groups. So that's a bit of an overview of kind of where I've been. And here's just a quick overview of some of the recent projects that we've been doing well. I've been at Manchester the last few years. So this first one is the pain that we published looking at ethnic inequalities in health related quality of life amongst older adults. So this was using a big national survey, which is actually the same survey I'll be talking about in detail labor and we found these really wide inequalities particularly between some ethnic groups. Yeah, a different kind of project that we've been doing was using NHS health records. So this was looking at inequalities in terms of who waits the longest in A and E to get treatment. And then do they get the right kind of treatment? And we found that patient's who live in more deprived areas actually wait longer for care and tend to get less, less kind of expensive treatment compared to other patient's who live in maybe in more affluent areas, but who are presenting with the same severity of conditions. And another another page that we did quite recently was looking at the COVID vaccine uptake. And again, I think you're probably aware of this from kind of national news stories, but we found evidence of really quite wide inequalities in uptake between different groups looking locally and Greater Manchester. And then it kind of related piece of work that we did. This was working with some analysts from NHS England who reached out to say they'd like some support with trying to evaluate how effective the rollout of the COVID vaccines has been preventing hospitalizations in England. So that's a bit of a kind of variety of things that we do. Obviously, there were different topics, they're different kinds of approaches, some of these health records, some surveys, but the kind of unifying theme is looking at inequalities between different social groups and and trying to understand what how those health inequalities arrives. So I'll leave that there and kind of now we want to today's the topic of today's tour, which is like an agenda based mental health inequalities in primary care. So I just want to take a pause before I dive in and just make sure we're kind of all on the same page about some of the terms that I'll be using. So when you think about gender, we need to remember what the difference is compared to thinking about sex. So sex is something that has a biological interpretation. It's usually something that is registered at birth based on the kind of visible body parts of a baby related to that. But different is gender or gender identity. And this is something that is socially constructed. It doesn't have an absolute, it's someone's kind of internal sense of whether they are a man or a woman or anything in between or beyond those buying categories. So in particularly in western cultures, there's been a kind of very dogmatic idea that there are two genders as man and woman. And I think over the last few years, we're kind of gradually is dying to recognize. Actually, there is much more gender diversity than that and other cultures have recognized this for for much longer. Um So there's a whole variety of terms that people use and of course, it depends partly uh you know, which social groups are really where you live, kind of how old you are, people use different terms and the language is evolving, but there are some kind of umbrella terms we can think of. So terms of kind of cover a number of identities that are quite useful and that's some of these terms of use of the day. So for example, non binary or transit or gender diapers. So what do we know about gender diversity in England? To be honest, not very much. Um One of the big reasons for that is that there isn't actually any official formal legal recognition of non binary or diverse genders. So obviously, this has to be effective kind of marginalizing people who are not buying real or gender diverse. But it also means we just don't really have any information about even the size of this population group or what their needs might be or any kind of outcomes. I think it's worth kind of pointing out that the UK is quite behind a lot of other countries on this. So there's a few countries that there that I've missed it but now have official recognition of third or additional genders. Um So for example, you can have up with your birth certificate, your passport or your official documentation. So kind of related to that. Um Obviously, one of the big ways that we count who lives in the UK is the UK census. So we just had one in, perhaps remember filling it in. There was quite a lot of debate about changing the questions on the census in including something to actually register what gender, ask what gender is everybody. But in the end, it was decided just to retain the been any question asked about sex. So we still don't have any recording of gender in that context either. But the senses did ask a second question asking about trans identity. So there was there was some progress there. We now have a that's a sense of what the population is. So similarly, since 2004, when the Generate Ignition Act was brought in trans, people can now legally change agenda from one binary to the other. So for a male to female or vice versa, but this remains quite a lengthy and intrusive process. And at least in England, it still requires a psychiatric diagnosis of gender dysphoria. So it's a very medicalized process in terms of health and healthcare, there's no routine or required recording of gender in NHS records. So your NHS record would just have no sex and there's no easy way or no kind of consistent way to recording trans identity in a health record. So a lot of confused systems just don't really have any facility to make that clear. It would just have to be written in kind of free text meds. So overall, then this whole picture is what gives us this lack of recognition and recording kind of across the board and it means that we have almost no information about populations or health and health outcomes. So what about gender of mental health then? So although we don't have kind of big picture statistics. What we do know is quite a lot of information that's been found from kind of smaller studies or qualitative studies. So the kind of research where people interview people and kind of talk to people and ask about their experiences. So from this, we know that trans non binary and gender diverse people experience discrimination in England and as with any marginalized group, like anything minority recall other minorities, there is a risk of West mental health outcomes because people experience the stress of being a minority and the stress of being treated and discriminated against. We also know that gender dysphoria, which is a sense of kind of discomfort or an ease with the discordance between the sex registered at earth and gender identity that can also increase the risk of poor mental health. Now, quite a lot of research has shown quite community that if people have access to gender affirming healthcare that can really resolve these mental health difficulties. But at the moment in the UK, it's really hard to get access to gender affirming care on the N H S. There's a long waiting list and there's a lot of barriers, a lot of kind of hoops to jump through. So that is kind of potentially exacerbating these risks. Quite a lot of people. So there's several things that might increase your risk of having a mental health condition. But people who have a mental health condition, if there are trans or non binary agenda that this might also face difficulties trying to access appropriate mental health support. And it's been quite a research into kind of experiences and why this might be. And there's kind of a few things that have come out of that. So one is kind of a fear uh or actual experiences of being discriminated against it and the stigma save addicted. There's also people are often concerned that the healthcare provider won't understand gender diversity. There's also the fact that as I've said, people can't have agenda accurately recorded in the health records. So they feel kind of marginalized by the whole system. And there's fear and actual experience of healthcare providers pathologize in people's identity. So I'm just gonna take merit to explain what I mean by that last point just to be clear. So there's quite a complex and ongoing legacy of trans and non binary identities being treated as mental health disorders. So it's actually only in the last few years of the World Health Organization removed being transgender as a mental health condition. So it used to be an international classification of diseases as as a known mental health condition. Of course, you're probably all too young to kind of remember back to the ninety's. But this has a lot of parallels how other queer identities have been pathologize in the past. So it used to be that homosexuality was considered to be a mental health condition and that used to be an international classification of diseases. So back in the 19 nineties, that was removed and that was updated and clarified, but there's an ongoing legacy from that even now. So even what 30 plus years late there, it's only now that the government's trying and kind of thinking about introducing legislation uh to ban so called conversion therapy for less than gay and bisexual people. But again, in a sign of kind of how far behind trans rights are in the UK the transfusions, you will probably be excluded from the status Lation. And similarly, you know, as I mentioned before, in the occasion, at least in England to change your gender legally, it still requires a psychiatric diagnosis. So again, it's conflating identity with a mental health disorder. Okay. So that's a bit of a back background of kind of just introducing the conflict. But what we're we trying to do in this study. So the first thing we wanted to do was estimate gender based inequalities then permanent and long term mental health conditions in England. The second thing we wanted to do was explore whether there are inequalities in uh mental health support within primary care and to work with charities and people with lived experience and try and understand some of the wider context around this. So just expanding a bit on that last point, what we did was we worked with staff from the LGBT Foundation, The Proud Trust 42nd Street and made by Mortals and this was working people, people with a range of kind of lived experience and professional experience. And we had a series of kind of different types of meetings and discussion groups and we talked about the context and also kind of the language that was most appropriate to use and have to kind of frame and report this sensitively in a way that felt kind of inclusive. I think I just wanted to emphasize this side of the research because you all are kind of starting out on your journeys into thinking about research and things. I think it is, it's increasingly something that's being done. And I think it's something that's really important, whether it's a particular community that you're doing research with about or whether it's in particular patient group or a particular type of medicine, it's so important to have that kind of patient voice or community voice and that limped experience and to make sure that the work you're doing is truly inclusive. You're not kind of doing research from an outside point of view about someone else, but you're doing research with whoever your research. So I've said a lot about how we don't have the information and nothing is recorded anywhere. But how did we do this? So what we were able to do is make use of changes to one of the big healthcare surveys. So up until transfer, Nitty, the G P patient survey, which goes out to lots of G P patient's every year just asked about sex. So are you male or female? But since 2021 it now asks which of the following best describes you with options, male or female, non binary, preferred to some prescribe or prefer not to say and ask the second gender question, which is where your general entity is the same as the sexual register of birth. So this obviously gives us a much more complete idea of people's gender. And so we're able to use this to provide some of the first national estimates of mental health inequalities. So one of the other advantages of the G P patient survey is that it is absolutely huge. So over those two years, we had about 1.5 million respondents and that means it's really useful for looking at minority groups. So well, there were no percentage of people identifies not bio. We actually had quite a few respondents who did six. So we could still do the analysis. So looking at the demographics and they're about 2600 people who said they were non binary, it's about 26000.2% and similar numbers who preferred to self describe agenda and and then slightly high portion who said that they would rather not set in terms of cysts or trans identity, the majority of assist gender, but they're about 8000 people who are transgender and again, a slightly higher precaution preferred not to answer that question in terms of the two outcomes we're looking at. So the first was a long term mental health condition and about 9% of people said they had a long term health conditions, mental health condition. And then the other was having fun. Met mental health things at your last CT appointment. So mental health needs is not going to be relevant to every GP appointment. But we first restricted outcome to it was about 40% of patient's who said their mental health needs were a relevant factor at the last appointment. And then within that, about 15% of people said those needs weren't actually met. So it's a minority but it's actually quite a few patient's per equipment. So looking at a bit more detail at at gender across uh sample that we had. So we split into different age groups here because we thought there might well be some generational differences. So what I'm showing you here is just if you look down the side, that's each gender group and across the bottom, it's the sensible trans identity groups. And in each case, the little number and the color is there's an indication of how many people are in that group. So the darker colors just be high numbers. So if we look at gender diversity, which we can think of as kind of any groups who are not cis gender male int as gender female, you can see that that's highest amongst under 35. It's about 3% overall. And it's most amongst the oldest age group. What's interesting is that there's a relatively high proportion of people who prefer not to say to both the gender and uh system trans identity question. Now, there's probably a whole range of reasons for that. And this might be quite a diverse group in terms of, you know, what motivated people to choose that box. But I think it's kind of important to remember that within that group, there might well be quite a lot of gender diverse people who don't trust the NHS with that information. So they didn't want to disclose their gender identity in an NHS survey. So it's really important to kind of look at outcomes for groups where you have missing data or not say because there might be quite a lot of inequalities in those groups. One other interesting thing that you can see here is that you can see in the younger age group, there's far more people who are non binary. And I think this is potentially reflecting genuine shifts and demographics, but also is likely to be partly about the language that people use to describe their gender. And that is of course shaped by your peers and you know, social media and everything else. So it might be the identities are actually quite similar across generations, but the language that you use to talk about it is evolving. Uh huh before I go into the main result and it's gonna give a little bit of information about the methods that we use. Please do put your hands up and stop me. But I think isn't clear because I don't want to lose you at this point. So we use something called a logistic regression model, which is not important. It's just the statistics that we did to try and estimate the probability that each, for each group of importing a long term mental health condition. And then we did the same thing for reporting that your mental health needs were not met. What we did was we have to eat gender route. So that's the five identical groups within each Cissel trans identity group. So we had 15 groups overall to try and get this quite detailed picture. We adjusted by the age group and serve a year. And that's just because we've already just seen that there's different gender profiles across the age groups. And on average younger people tend to report a mental health condition more often than older people. So we just want to just out any differences based on that. We also then did something called mediation analysis and I think you probably won't know what this is. So I'm just going to get a quick explain it. So when we're doing this kind of statistics, what we're doing is we're saying okay, we've got gender on one end, we can think of that as the exposure, then we adjust for a couple of things that we think might be causing a difference. But we're not interested in, we just want to adjust the help. And then on the other end, we've got that causing the outcomes. But that auditory only tells us so much. So gender is not really likely in and of itself to be causing differences in mental health in the same way that people being from different, different ethnic backgrounds is not likely to cause kind of inherently in and of itself the differences in health that we see in this country. What we need to know is what social stuff is on that corner of chain between the exposure at one end and the outcome of the other. So we can think of these things as mediators. So in this case, one example would be we know that people from gender minority groups experienced discrimination. So that's going to limit the kind of socio economic opportunities they can have, it might lead to things like housing and security, employment, security, poverty. And we know that each of those things is a risk factor for worth mental health because their major stresses in people's lives. So we can think of that as kind of competing this chain of events from generate one and two mental health outcomes of the other. So mathematically what we can do if we take those socioeconomic variables, we take that information, add it into a model if that is an important path link on this average, we'll see the inequalities collapsed down. So that's what we're looking for as we add things in. Do we see those inequalities reduced? So another one we looked at was physical health. We know that trans non binary in general, there's people face barriers to health care. Uh We know that physical health is really an incremental health. And we considered this not really to be relevant to the first outcome. But we also looked at communication between healthcare professionals. So GPS and other doctors and um you know, other primary care staff, communication between them and patient's and with the patient's reported that they felt they could trust and whether they had confidence in the healthcare professions that they thought. So we thought that might be one of the things on the pathway between gender and other mental health needs. So getting into the main results then, so this is first looking up the probability reporting a long term mental health outcome. So across the bottom here of the graph, we've got cyst and transit density and then show them the key there, we've got each of the gender groups. So what I'm showing is the probability of reporting a mental health condition. So the higher up the points are the worst outcomes, the back. Great. So you can see there's some really wide inequalities here for the agrees with the kind of lowest probability of a mental health condition. It's hovering around kind of 10 12% but for the group of the worst outcomes, transgender and or buying people, it's close to 50%. There was also really hyper mobility for trans patient's who self described their gender. And for non binary patient's who prefer not to say they're cysts or translate density. Looking across the group's inequalities aren't as large, but they tended to be higher for trans, been there to assist gender patient's within each of the gender groups. So then looking at potential mediators, what's driving these differences. So first we added in a lot of health variables. And so is this to do with differences in physical health? So if you compare the two graphs, there's some reduction in inequalities but they look broadly similar. So we can say that perhaps a component of it is to do with physical health differences, but it's not a key driver here, we then added some socioeconomic variables and again, it decreases a little bit further. So we can say that probably there's a component of socio economic inequalities, but most of the inequality remains there. So most of it is not explained by this practice. So we think probably that's because we don't really have stuff in the G P patient survey that really captures minority stress very well and that's likely to be a big driver here. So moving on to the second outcome, then looking at both the mental health needs. So here the probability of having on the mental health needs was lowest for male and female patient's with this gender. For all the other groups, there was higher probabilities on that mental health needs. Um Although across these are the groups, there wasn't really any statistical differences, there was a trend towards the highest um on many patients who self described agenda or you prefer not to say that's just intransigence. Um So again, they're looking at what might mediate this. So first we added the same health and socioeconomic variables as we can for the last outcome. And you can see maybe there's a little bit of reduction here, but again, not really, we don't have the virus yet, but we then added in the communication and trust variables. And you can see that there's an equality that really collapsed down. So quite a lot of groups, there's no longer any statistical difference. So what we can conclude from this is that inequalities in the way that gps and other primary care staff are communicate with patient's might explain a lot of the inequalities for the trans, not Ireland and gender diverse patient's. So to some of what I told you then, uh in 2021 the GP patient survey became the first major health and care survey to have inclusive gender questions. We've used this to provide first nationally represented estimates of gender related mental health inequalities in terms of inequalities and mental health conditions. We found that they were very much increased amongst transgender patient's. Uh assist gender patient's. And those uh preferred not to say, we also found within the additional inequality for non binary Asians and for those who self described agenda intends to own that mental health needs. We found increases amongst all gender diverse groups compared to cis gender, male and female patient's. And we found pretty good evidence that this is likely to be mediated by inequalities in health care professional to patient communication, add relationships, You got it. Oh yeah. So these results together with lots of that kind of previous evidence that I was talking about at the beginning suggest some of the changes that are really needed to help improve these inequalities. So one key thing is we really need to improve the recording of general and energy health records. So we have this clear evidence now that this is not just some people, this is a population level, we see these clear inequalities, but in order to kind of monitor and improve the situation, we need to have this recorded so that there can be more research and kind of audit and keep track of things and making progress. One key thing to remember though is that this needs to be done in a way that prioritizes inclusivity and affirmation, but also keeps track of patient safety. So there are things where the NHS needs to know which sexual assigned at birth in order to invite you for the correct things like preventative cancer scream. So for example, it's really important that your health record accurately reflects whether you have a cervix at the moment, trans patient's are often left without access to the right health care because they're faced with the choice of keeping the wrong gender marker or changing their sex market. So it's these kind of things that we need new systems for them to try and make swear informations. And it's clear that we also need that training of healthcare professionals so that they can work well and confidently with all their diverse patient's not just groups. I think, you know, improving communication and trust is really key to that. So there's a great program blamer by the LGBT Foundation called Pride In Practice. And they're having some great results with training up people in primary care to be confident, working with all kinds of actions. I think looking a bit more broadly, there's also a clear need for improved access to gender health care, for people who need it and broad. It's still an improvement in the kind of general legal and social environment for all terms, not by any and genders, I guess people. So I'll leave it there intense of the findings, but just want to acknowledge all the public contributors who worked with us along the way. And the staff from each of the charity's also thanks to the team at the university who helped with the public involved rehabilitation and the rest of the research team and the hr funding. So I'll take any questions. So that's thanks Ruth. I think we really, we all really enjoyed that. Does anyone have any questions? And my folks? Um so you mentioned some, you're talking the US, especially in New York and Florida. So I'm just wondering if there are any kind of health and apologies in particular that you found were more parent in those areas, especially compared to the UK. Yeah, I think being in New York, um I mean, it's, it's a city of extreme contrast. You've got the ultra wealthy people there and you have huge amounts of poverty. So I was working, it was the kind of the edge of Harlem and you know, Harlem is, it's a really bad, vibrant, great neighborhood, but it also has real poverty and I think it's just very apparent when you look, I think it's probably, you know, you can say the same of any big city, but I think the US, the extremes are just more extreme than we're used to seeing him because there's less of that social safety net. There isn't an NHS, some people just don't have health insurance and then they just can't have healthcare. And I think as someone who's used to an NHS type system and, and kind of, I mean, we can't call benefits generous at this point for like some sense that there is a wealth testing to them. Be in New York is confronting, I think probably in a good way because there's lots of it here. We just, it's not as extreme and you can even look at more. But yeah, good question. You ask a question. I have a statement to make rather than a question. If you make me want to quit surgery, I don't care questions. And what like, what should we do and to quell this cap, I think one of the things that you can easily all do kind of every day, I think is just reflect on each inter actually have other patient. I think we're all human and there's people that will click with easily. There's people who relate to easily, but every patient deserves the same kind of time taken, the same thoughtfulness, the same kind of open questions rather than making a some options. And I think probably that's the biggest thing you can do in a kind of everyday way as well as kind of pushing for change and kind of, you know, advocating for changes to medical education. You know, there's also all the kind of, you know, women's health, that side of gender equality. And I think there are a lot of big picture changes needed, but I think a lot of it also comes from each interaction with health care. All right. Thank you. That was very informative. It was very interesting. So we have the ground cause free