INTRODUCTION
Patients’ sexual orientation is perceived as a difficult topic and one frequently avoided by GPs.1 The 2010 UK Equality Act2 made discriminating against people due to nine characteristics, including sexual orientation, illegal and also created a legal requirement for organisations, including the NHS, to promote equality for lesbian, gay and bisexual people (LGB), including transgender individuals. The General Medical Council3 (GMC) website has guidance regarding sexual orientation instructing doctors against discrimination,4 which highlights to medical students the inequality of health care for LGB. An article by the LGB charity Stonewall contains recommendations for GP care,5 and in April 2014, the GMC wrote a leaflet in conjunction with Stonewall for LGB patients clarifying their expectations for medical care.6 Most of the cited recent research on sexual orientation has been written by or in conjunction with LGB charities leading to potential selection bias.
INEQUALITIES IN HEALTH CARE
Research by Stonewall found differences between the health needs of LGB and heterosexual patients. LGB patients have twice the incidence of mental health disorders including depression and suicide. Uptake for health screening is reduced in LGB; only 64% of lesbians had had a cervical smear compared with 80% nationally. Overall, they engage in more health-adverse behaviours; such as, smoking, alcohol excess, illicit drugs, and risky sexual behaviours.7,8
PATIENT AND PRACTITIONER OPINIONS
The Manchester Clinical Commissioning Group, as part of their Building Health Partnerships project with the Lesbian and Gay Foundation (LGF) undertook a LGB patient survey: 34% of responders claimed their GP assumed they were heterosexual, rather than ask about their sexuality, which they felt was discriminatory.9 In 2011, Stonewall found that 33% of bisexual and gay males had not informed their GP of their sexual orientation,8 with the Manchester survey uncovering a similar percentage.9 In 2011, a review of 12 publications interviewing GPs and practice nurses investigated why clinicians were uncomfortable talking about sex and sexual orientation.10 Reasons given were embarrassment, fear of offending patients, and being judged as discriminatory. Another study found patients wanted to talk to their GPs about their sexual orientation, and wanted GPs to initiate these conversations.11 The Manchester study also interviewed 26 GPs, confirming the majority supported identifying the sexual orientation of patients, but expressed concerns understanding new sexual terminology, and initiating a lengthy discussion without having the necessary time or experience.1
In 2014 I undertook a questionnaire survey (a poster presentation at the Royal College of General Practitioners Annual Primary Care Conference 2–4 October 2014, in Liverpool), of 81 GPs across England and found that 54% felt it was important to be aware of a patient’s sexual orientation, 34% considered it unimportant, and 12% held mixed views on the subject. Reasons given for the importance (of being aware of a patient’s sexual orientation) were avoidance of GP and patient embarrassment, normalisation of discussions regarding sexual orientation, and to facilitate a LGB-significant diagnosis and help tailor health promotion. The reasons for not monitoring sexual orientation were lack of relevance, difficulty in discussing sexual orientation and the potential to offend patients, risks of stereotyping patients leading to prejudice, and maintaining data confidentiality. However, informal conversations with some GPs showed that many seemed to be confusing anonymisation of data with confidentiality.
DOCUMENTATION OF SEXUAL ORIENTATION
In my survey, of those monitoring sexual orientation, 4.3% of GPs routinely documented this in patients’ records, 26% sometimes documented, and 65% never documented. Of those who recorded it, only 18% used Read Coding in the medical summary or other computer module facilitating easy retrieval for reference, or readily identified in any data search. Some GPs mentioned that their historical knowledge of patients leads to sexual orientation being discussed within consultations without formal documentation, though appreciated this to be unsustainable.
In 2009, Ellison and Gunstone looked at the public acceptability of a questionnaire on sexual orientation, 75% of people felt it was acceptable to ask questions about sexual orientation in large national surveys.12 Another survey showed responders would be least likely to conceal their sexual orientation when using self-completion online surveys, rather than in discussions face to face, suggesting a practice questionnaire may produce more accurate data.13 Of those responding to the Manchester patient survey, 90% said they would enter their sexual orientation on a practice questionnaire.9 Including sexual orientation on a patient registration questionnaire could ensure Read Coding, would obviate GPs concerns regarding sexual terminology, and could enable LGB patients to discuss sexual orientation along with any associated or non-associated health concerns in a perceived non-judgemental environment.
THE WAY FORWARD?
As discussed, routinely documenting sexual orientation of patients will help to normalise the topic within practices. This will increase awareness of the primary healthcare team to sexual orientation, give confidence to practitioners to discuss the topic with patients, and make this a more ‘normalised’ part of patient care. Being aware of a patient’s sexual orientation facilitated by documentation potentially improves primary healthcare provision including focused health promotion.
In the report on monitoring sexual orientation in the health sector, discrimination in the NHS was raised, and it was felt that:
‘It was not appropriate to introduce universal patient monitoring until the health sector is able to demonstrate a more universal acceptance of LGB people’.14
The introduction of Care Quality Commission inspections to GP practices has led to regular IT governance and equality and diversity training for all GP practice staff. One of the visit’s ‘outcome’ assessments is that care and treatment is provided regardless of the patient’s sexual orientation, raising the awareness of practice staff on issues of confidentiality and sexual orientation.
Some initiatives already exist: the Pride in Practice project run by the LGF and supported by the RCGP, is a self-assessment by GP practices, highlighting areas for service improvement for LGB patients and providing advice to increase their involvement and minimise any perception of homophobia. Greater publicity of the Pride in Practice award would produce a nationally-recognised gold standard against which practices can be compared.
The RCGP curriculum which forms the foundation of GP training includes a curriculum statement on sexual health, requiring a doctor to:
‘Take a sexual history from a male or female patient in a way that is private and confidential, non-judgemental, responsive to the reactions of the patient and avoids assumptions about sexual orientation or the gender of the partner(s)’.15
While this will influence young GPs and trainers, more experienced GPs in clinical practice may not aware of this increased educational focus.
The recent studies show that concern around GPs’ awareness regarding sexual orientation still exists, and my recent survey confirms this; in particular, the lack of GP’s communication skills in discussing this clinical area. This may be due to a historical lack of inclusion of this topic and its vocabulary in medical undergraduate education, as well as a lack of updating, or cultural issues around sexual orientation for some practitioners (an important point requiring further investigation). Stonewall and the LGF have tried to address these issues with leaflets directed at medical practitioners and clients, but more training in matters regarding sexual orientation as part of an equality and diversity agenda is required. Documentation of sexual orientation will help to ‘normalise’ this area for both practitioners and patients, and help address these issues.
Notes
Provenance
Freely submitted; not externally peer reviewed.
Competing interests
The author has declared no competing interests.
- © British Journal of General Practice 2015