Sexual orientation monitoring and documentation: intrusive or important for patient care?

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.