Inequalities and mental health

This page outlines the key public mental health challenges faced by selected seldom-heard and/or marginalised groups, some of whom are recognised by the NHS as part of its ‘inclusion health’ groups.

Inclusion health is a term used by the NHS to describe people who are socially excluded and who often experience multiple, overlapping risk factors for poor health - such as poverty, discrimination, violence, and complex trauma. These groups typically have significantly worse health outcomes than the general population, including lower life expectancy, contributing to widening health inequalities. 

The groups we focus on here are:

• Black mothers
• Gypsy, Roma and Traveller communities
• Undocumented migrants
• Care leavers
• LGBT+ youth

It is important to note that these policy summaries are written in the context of England. While many of the recommendations refer to the powers of the UK government at Westminster, the issues identified will also be relevant to the devolved nations. 

Black mothers in the UK face significantly higher risks of mental ill health, including anxiety and depression. These challenges are compounded by barriers to accessing appropriate care and systemic failings across the NHS.  

Inequalities in antenatal and postnatal care

Pregnant Black women are at particular risk of poor mental health. Research has shown:

• Black mothers are over twice as likely⁴ to be admitted to hospital with perinatal⁵ mental illnesses than their white counterparts, suggesting that they are reaching crisis point before getting proper support.
• White women are more likely to be offered treatment for postnatal depression and anxiety than Black women.⁶
• Black women are almost four times more likely to die during pregnancy and childbirth.⁷

These inequalities combined with widespread reports from Black women of negative experiences in maternity care, can be a significant source of anxiety for expectant mothers. One study found that ethnic minority women – with Black women forming a large part of the sample – were twice as likely as white women to worry about childbirth, even after adjusting for factors such as age, education and income. ⁸ 

Experiences of neglect in health services are also common. A survey by Five X More, a Black maternal health organisation, ⁹found that:

• 40% of respondents were not asked about their emotional wellbeing by health care professionals.  
• Of those who were asked, two-thirds were not given support or resources.  
• More than a quarter were never asked about their mental health at postnatal appointments.

This neglect of adequate care for Black mothers has serious consequences for their mental wellbeing during such a critical and life changing stage in their lives.  

Systemic racism in healthcare

Systemic racism¹⁰ and a lack of cultural competence among healthcare staff are key drivers of these disparities, fuelling mistrust and reluctance to seek care and support.  

• Dismissal of concerns: Many Black women report feeling ignored or dismissed by healthcare professionals. One study found that many were made to feel as if their “thoughts and feelings do not matter”, while others said concerns were trivialised or treated as exaggerations.⁹ This lack of validation can cause anxiety and distress throughout pregnancy.  
• Pain minimisation: A widely reported issue is the denial of appropriate pain relief during labour. These instances are based on racial stereotypes that Black women are strong and have high pain tolerance. ¹¹Such racist beliefs are dangerous and increase stress and the chances of long-term mental health problems including PTSD.
• Inappropriate cultural assumptions: Some Black women reported cases of racially ignorant remarks when attending appointments alone – including assumptions of pregnancies being unplanned or intrusive questions about the father’s involvement.  ⁹

The challenges Black mothers face in healthcare intersect with broader inequalities. Black communities in the UK are disproportionately at higher risk of being socially disadvantaged – being more likely to experience poverty, housing insecurity and discrimination.¹² These factors further increase the likelihood of mental ill health. 

Recommendations

To improve health outcomes and rebuild trust between Black mothers and health services, urgent action is needed, including:

• Culturally competent care: NHS England should implement mandatory training for all healthcare professionals, particularly midwives and obstetricians, on racial bias, cultural sensitivity, and the specific health needs of Black women. This training should be co-produced with Black-led health organisations.
• Better data collection and transparency: Development of an annual survey, co-designed with Black-led organisations, to capture the experiences of Black women in maternity care – similar to the existing CQC maternity survey.  
• Greater investment in community approaches: Government and NHS bodies should collaborate with community organisations that provide culturally relevant support and advocacy and fund research targeted at Black maternal health.
• Stronger feedback systems: NHS trusts should streamline how they collect feedback and complaints, ensuring ethnicity data is recorded. This would reveal disparities, highlight areas of improvement and hold health services accountable. These systems should also align with the Patient and Carer Race Equality Framework, produced by NHS England, which aims to improve experiences and outcomes for ethnic minority groups in mental health services. 

Gypsy, Roma, and Traveller (GRT) communities face some of the starkest mental health inequalities of any ethnic group in the UK. Despite clear evidence of need, they remain overlooked and underserved by public mental health services, leaving them at higher risk of poor outcomes and enduring inequities.

Mental health outcomes

Research shows consistently high rates of mental ill health among GRT people.

• Gypsies and Travellers are more than twice as likely to experience depression and three times more likely to experience anxiety compared to the general population.
• In Ireland, suicide rates for Traveller men are seven times higher than in the wider male population and account for 11% of all Traveller deaths.13  
• A 2020 study by the GRT led charity, GATE Herts, found that 32% of Romani Gypsies respondents reported having relatives who had attempted suicide in the previous five years.  ¹⁴

These findings show that GRT communities experience worse mental health outcomes compared to the general population and the factors for why this is the case are multi-faceted and intersectional.  

Societal prejudice

Prejudice and discrimination against GRT communities is widespread and deeply entrenched.

• A 2018 study by the Equality and Human Rights Commission (EHRC) found Gypsy and Travellers faced some of the highest levels of prejudice of any ethnic group in the UK.¹⁵
• A 2021 YouGov poll found that 45% of people would feel uncomfortable with a Gypsy or Traveller neighbour. ¹⁶

Such pervasive stigma spills over into healthcare. GRT communities report difficulties¹⁷ in registering with a GP because of a lack of cultural awareness¹⁸ and assumptions that they will be ‘expensive patients’. Some GPs are also reluctant to visit sites, while a lack of cultural competence among staff leads to poor engagement. Poor literacy and complex registration forms also create barriers, with little professional support offered to assist them.¹⁹ This institutional neglect from mainstream services prevents many GRT people from accessing care when they need it most.

Cultural Stigma

Community factors also play a role with discussions surrounding mental health being a taboo subject.²⁰ In some Roma communities for example, there is a strong belief that mental health problems are primarily caused by genetic factors. ²¹This can jeopardise the future prospects of marriage for the individual and even their relatives. Among Traveller communities, the term “mental health” is often avoided with alternative terms such as “bad nerves” being used instead.12 Without cultural awareness and understanding of these perspectives, health services may struggle to engage effectively with such communities.  

Intersecting identities also compound stigma. Gypsy and Traveller men for example face prejudice from wider society while also navigating strict gender expectations within their communities, where acknowledging mental health problems can be viewed as a weaknesses. Women within these communities meanwhile often experience gendered pressures without adequate support systems and suicide rates among Gypsy and Traveller women aged 25-64 are more than twice than those of white British women.²²

Lack accurate and detailed data

A major barrier to progress is the absence of reliable, detailed data and the difficulty in collecting it. ¹⁹These difficulties are attributed to many people in GRT communities avoiding disclosing their ethnicity for fear of discrimination, while health services often fail to record their identities in meaningful ways. This lack of disaggregation makes it difficult to measure the true scale of mental health needs or the effectiveness of interventions.  

Recommendations 

To reduce mental health inequalities amongst Gypsy, Roma and Traveller communities in the UK, we need:  

• Culturally competent services: Mental health services should be co-designed with GRT communities, recognising their diverse histories, beliefs and needs.  
• Improving outreach services: Providing more innovative services from online/virtual services and mobile therapists to easily accessible drop-in sessions.
• Better data collection and analysis: Collect and publish disaggregated national data on GRT populations and their use of NHS services to better guide funding and service design.
• Public campaigns: Challenge prejudice, reduce stigma and normalise conversations about mental health within GRT communities.  

Undocumented migrants are a particularly at-risk population that face poor mental health outcomes. This is in large part due to the fact that their insecure immigration status prevents them from being able to properly access mental health services.  

Who are undocumented migrants? 

An ‘undocumented migrant’ refers to someone living in the UK whom the government does not consider has the right to remain.²³ Many undocumented migrants initially arrived through legal routes but later lost their status – for example by having a failed asylum application, overstaying a visa, being unable to pay expensive visa application fees, or after experiencing domestic abuse or poor legal advice.   

It is difficult to determine exactly how many undocumented migrants live in the UK but estimates typically range between 800,000 to 1.2 million people.²⁴ One study by Pew Research estimated that the most significant region of origin for the UK’s undocumented population is from the Asia-Pacific region (52%) followed by Sub-Saharan Africa (20%), the Americas and non-EU Europe (16%) and the Middle East/North Africa (11%).²⁵   

The UK’s undocumented communities are more settled than those in other parts of Europe, with over half having lived here for more than five years.²⁴ Additionally, over a quarter of undocumented people (215,000) are children, half of whom were born in the UK.²⁶ As a result, most undocumented people have family in the UK, often their only source of support, whether financial, emotional or otherwise. 

Mental health outcomes 

Research shows that undocumented migrants are high risk of mental ill health. Despite there being a lack of evidence and statistics, some international studies still exist on this topic. For example, one European study from 2022 found that undocumented people face a higher likelihood of experiencing depression, anxiety, and post-traumatic stress disorders (PTSD) when compared to both the general population and documented migrants.²⁷ In France, it was found that one out of six undocumented migrants suffer from PTSD - at least eight times higher than in the general population.²⁸ Moreover, PTSD, anxiety, and depression were also the most reported mental health outcomes among undocumented migrants in Sweden.²⁹  Such figures highlight the heavy psychological burden of living with insecure status, poverty and fear of deportation over a long period of time.

Barriers to good mental health 

Undocumented migrants face many of the same barriers as asylum seekers, compounded by hostile/compliant environment policies³⁰ that make daily life difficult including their ability to access public services. These policies have no clear evidence of deterring migration but have serious consequences for people’s mental health and wellbeing. These include:

Legal and financial restrictions

• Employment: it is a criminal offence to work while undocumented and employers must conduct “right to work” checks. This leaves many people vulnerable to exploitation in informal jobs while the fear of being reported makes it hard to challenge unsafe conditions or unfair pay.³¹
• Housing: undocumented migrants are barred from renting property and landlords must conduct “right to rent” checks.
• Financial services: people without status are barred from opening a bank account, making it almost impossible to manage money securely whilst pushing them further into poverty and destitution.
• No Recourse to Public Funds: undocumented migrants are ineligible to access most state benefits.  

Healthcare access 

• Proof of ID: Many GP practices wrongly refuse to register patients without documents, despite NHS guidelines explicitly not requiring the request of ID.³²
• Fear of data-sharing: Some migrants avoid healthcare services altogether, worrying that their details may be passed onto the Home Office, putting them at risk of deportation.³³
• Healthcare Costs: Free access to secondary care is also limited to those with legal residence in the UK and charges can be far higher than standard NHS costs.³⁴  

Other barriers

• Complex rules: many migrants (and some frontline staff) do not understand the eligibility rules, exemptions or complaints routes, so errors go unchallenged and necessary care is missed.
• Lack of affordable visa routes: The UK’s immigration fees are among the highest in the world and they continue to increase.³⁵ This makes it difficult for undocumented migrants to find affordable ways of regularising their status, trapping families in limbo and further discouraging engagement with the Home Office.
• Language barriers & lack of interpreters – shortages of qualified interpreters and written information in other languages make it difficult to book appointments, describe symptoms and/or navigate treatment.  

Together these barriers create destitution, social isolation, and ongoing stress and anxiety for countless undocumented migrants - all of which severely undermine mental health. 

Recommendations

To reduce the mental health inequalities for undocumented migrants in the UK, actions need to be taken including:  

• The UK government should dismantle all remaining hostile/compliant environment policies while removing immigration enforcement duties from public service providers including the NHS.
• In its place, policies and measures should be put in place that create an immigration system that is more efficient, cost-effective and humane. This would guarantee that everyone, irrespective of status, can seek timely, unconditional access to essential services, especially mental health care.
• The UK government, devolved administrations, and NHS services should develop and deliver training for healthcare staff on the healthcare rights and entitlements of undocumented migrants.
• The UK government, devolved administrations, and the NHS should ensure healthcare services provide appropriate professional interpreters. This is an important step in ensuring undocumented migrants can engage with healthcare services and are supported in navigating an unfamiliar healthcare system.
• All visa routes should be affordable. The right to stay in the UK should not depend on whether the applicant can afford the fees and immigration fees should be set no higher than the cost of processing an application.  

Care leavers are among the most vulnerable groups in the UK when it comes to mental health. Moving from care to independent living is often described as emotionally, financially and personally challenging. Many face significant barriers to support at a time when stability is most needed.   

Mental health outcomes

Children in care and care leavers are more likely to have experienced early adversity including abuse, neglect or other forms of trauma.³⁶ These experiences can have lasting effects on mental health, contributing to higher rates of depression and anxiety.³⁷ According to the children’s charity Barnardo’s: 

• 45% of children in care have a mental health disorder compared to 1 in 10 in the general population.
• They are four to five times more likely to attempt suicide in adulthood.
• 65% of young people identified as having mental health needs were not receiving any statutory service.³⁸  

These statistics show a clear need for targeted, consistent mental health support.   

Barriers to good mental health

• Lack of awareness and trust  

Research by Ofsted found that a third of care leavers did not know how to access mental health support.³⁹ One of the Foundation’s Young Leaders explained:  

Many described feeling ‘alone’ or ‘isolated’ when they left care, often tied to a lack of trust in professionals.³⁷ Many young people feel that social workers are overstretched, inconsistent and/or disengaged. 

• Hurried transitions

More than a third of care leavers told Ofsted they left care too early, often without adequate preparation. Many were not taught essential life skills such as budgeting, cooking or shopping – leaving them unprepared for independent living.  

Although statutory guidance⁴⁰ requires that young people should be introduced to their personal adviser (PA) from age 16, over a quarter of care leavers did not meet their PA until they were 18 or older. Instability in their relationships with their PAs was also a major problem.

• Housing insecurity

Stable housing is vital for mental wellbeing, but many care leavers lack choice or control over where they live. Only one in three care leavers had a say in the location they’d like to live in and just one in five in the type of accommodation.³⁷ Alarmingly, one in ten reported that they “never felt safe” when first leaving care.  

Benefits of tailored support

Having quality support during the transition to independent living can make a huge difference for care leavers’ mental health. During the Covid-19 pandemic, the Feeling Our Way programme – delivered by the Mental Health Foundation and Nottingham City Council – supported care leavers aged 18-25 with digital and physical resources, from mindfulness tools to smartphones with unlimited data and therapeutic support.⁴¹

The programme helped young people cope with stress and reduce loneliness, showing how dedicated and specialised interventions can improve wellbeing beyond crisis periods. Raising awareness of available services is also essential. As our Young Leader put it:  

Strong relationships with PAs are critical, not just for practical support but also for trust and empowerment. Giving care leavers genuine agency in their decisions is essential to supporting their development into an independent young adult.

Recommendations

To improve the mental health  outcomes for care leavers in the UK, key steps should include:  

• Proper allocation of PAs: Local councils should ensure that all young people are introduced to a PA by age 16, in line with statutory guidance.  
• Youth-centred planning: Local councils, care homes, foster agencies should develop care plans with children and young people, preparing them for independent living and addressing their concerns about safety, housing and future goals.
• Access to advocacy: Local councils, care homes, foster agencies should ensure that all children in care and care leavers know how to make a complaint and have access to advocacy services.
• Targeted strategy: The UK government should develop a dedicated mental health strategy for care leavers, including trauma-informed practices and culturally competent services.
• Better oversight and accountability: The UK government should strengthen oversight mechanisms to ensure that care services are compliant with statutory guidance.  
• Housing security: Local authorities, supported by government, must guarantee care leavers access to safe, stable and affordable housing.  

LGBT+ young people face unique challenges that place them at higher risk of poor mental health. Despite progress on LGBT+ rights, homophobia and transphobia still remains a major cause of distress, whether that occurs in the home, in schools or in wider society. Growing up in an environment where stigma remains can greatly undermine self-esteem, increase isolation and cause lasting psychological distress.  

Mental health outcomes

LGBT+ young people in the UK face significantly higher rates of mental ill health compared to their cisgender,⁴² heterosexual peers. A 2021 survey conducted by Just Like Us found the following: 

• Anxiety: Half of LGBT+ youth reported experiencing or having experienced an anxiety disorder, compared to a quarter of non-LGBT+ peers.  
• Depression: LGBT+ youth are nearly twice as likely to experience depression.
• Self-harm and eating disorders: LGBT+ youth are three times more likely to self-harm and have an eating disorder.  
• Suicidal thoughts: Over two thirds of LGBT+ young people reported having experienced suicidal thoughts, more than double the rate of their peers.  ⁴³

It is clear that LGBT+ youth are a particularly at risk of mental ill health and are in urgent need for targeted mental health support. The factors for why this is the case are multi-faceted and include both social and structural inequalities.  

Barriers to good mental health  

As previously discussed, prejudice - including homophobia, biphobia and transphobia - remains widespread across society. These experiences can occur in peer groups, families, schools, and even public services, creating environments that invalidate LGBT+ identities and worsen mental health.

• Schools

School is often where many LGBT+ young people first encounter discrimination. According to research: 

• They are twice as likely to have been bullied in that past year compared to their non-LGBT+ counterparts.  
• Only 58% of LGBT+ pupils reported feeling safe at school compared to 73% of non-LGBT+ pupils.  ⁴¹
• Half of LGBT+ students also regularly hear homophobic slurs, while fewer than half receiving positive messaging about LGBT+ identities.⁴⁴

 The way LGBT+ identities are treated in schools has a direct impact on mental health outcomes. Research has shown that pupils whose schools had positive messaging about being LGBT+ also had reduced suicidal thoughts and feelings, regardless of their own sexuality or gender identity.⁴⁵This emphasises the importance of inclusive education and positive school environments that promote mental wellbeing.  

• Family and community rejection

Not all young people feel able to be who they are in their own home. A 2018 study by Stonewall, found that only half of lesbian, gay and bi people and trans people felt able to be open about their sexual orientation or gender identity with all members of their family.⁴⁶The inability to “come out” safely within one’s family can be a source of significant distress and can lead to feelings of isolation, depression and anxiety.

Family rejection can also lead to housing insecurity. According to the homelessness charity AKT, LGBT+ people are twice as likely to experience hidden homelessness (such as sofa surfing or squatting) than their non-LGBT+ counterparts.⁴⁷ LGBT+ youth from racialised communities face an even greater risk – being 50% more likely to experience hidden homelessness compared to their white counterparts.⁴⁵

Rejection can also occur within faith and cultural communities, spaces which are help to provide protection from broader societal prejudices such as racism and Islamophobia. It was found that a third of lesbian, gay and bi people of faith, and one in four trans people of faith, are not open with anyone in their faith community about their identity.⁴³ This enforced isolation from both family and community can therefore compound trauma and further undermine wellbeing. 

• Barriers to healthcare 

LGBT+ youth - particularly trans youth - face significant systemic challenges in accessing appropriate and timely healthcare. In 2024, over 5,700 under-18s were waiting an average of 100 weeks for their first gender identity clinic appointment. ⁴⁸These long delays can be a source of chronic anxiety while also making social transitioning much more difficult.⁴⁹

At the same time, the wider youth mental health system in the UK is overstretched. For LGBT+ youth, these systemic pressures compound the inequalities they already face. In 2022-23, according to the Children’s Commissioner: 

• Nearly one million children and young people had active referrals for mental health services in England.  
• Over a quarter were still waiting for support and 40% had referrals closed before receiving support.  
• Almost 40,000 children waited at least two years for support.  ⁵⁰ 

Through discussions with our LGBT+ Young Leaders, they offered additional perspectives which often described how many mental health professionals as being overly clinical, focusing on note-taking and confidentiality warnings rather than providing a space where they felt comfortable to speak openly about the issues they faced concerning their sexuality and/or gender identity. Others also mentioned a lack of cultural competency especially for those who were from ethnic minority backgrounds which left them feeling further unsupported.  

Additional barriers  

Beyond bullying, family/community rejection and access to services, there are other critical barriers that disproportionately affect LGBT+ young people’s mental health including:

• Conversion therapy: harmful practices aimed at changing an individual’s sexual orientation or gender identity remain a threat. Around 1 in 6 LGBT+ young people reported being threatened with or subjected to conversion therapy, which is linked to higher rates of  depression, anxiety, and suicidal ideation.⁵¹ Despite government pledges, a comprehensive ban on such practices is still not in place.  ⁵²
• Intersectional barriers: LGBT+ young people of colour often face overlapping discrimination – from racism within wider British society and prejudice within LGBT+ spaces. This double marginalisation can lead to greater isolation, reduced access to culturally competent services, and heightened vulnerability to mental ill health.  

Recommendations

To effectively tackle the mental health inequalities for LGBT+ youth in the UK, key actions need to be taken including:  

• Inclusive schools: Schools should continue to enforce and implement clear anti-bullying policies that explicitly protect LGBT+ students and promote inclusive education.
• Greater investment in youth mental health services: The UK government should properly fund services, reduce waiting times, and ensure staff are trained in LGBT+ and intersectional issues. It should also improve access to gender-affirming care for trans youth.
• Suicide prevention: The UK government should develop LGBT+ youth-specific strategies in partnership with LGBT+ organisations and those with lived experience.
• Housing support: All local authorities must address the needs of LGBT+ youth in homelessness and housing strategies, with particular focus on youth of colour and those from low-income backgrounds.
• Gender-affirming care: The UK government should dedicate more funding to the improvement of services and support for gender affirming care.
• Ban conversion therapy: The UK government should end the delay in implementing a comprehensive and enforceable legislative ban on conversion therapy with clear legal consequences and support services for survivors.