Promoting Equality and Valuing Diversity for Lesbian,Gay,Bisexual and Trans Patients

Understanding the social context for LGBT communities

Lesbian, gay and bisexual (LGB) people comprise a heterogeneous group: they are old and young, black and minority ethnic people, disabled, from any class or any faith group. They may be single, in a civil partnership with someone of the same sex (or they may be married to a person of the opposite sex) and they may have children. They may also be asylum seekers, refugees, homeless, prisoners or people living in poverty. Estimates suggest they comprise 6% of the UK population, which is 3.6 million people. LGB people can often only be identified if they disclose their sexual orientation (i.e. ‘come out’ as lesbian, gay or bisexual). Evidence indicates that they may be less likely to come out in health care than in other public environments because the experience of illness may increase feelings of vulnerability.

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LGB people are more likely to report incidents of lifetime and everyday discrimination than their heterosexual counterparts. They are exposed to higher levels of unpredictable, episodic and day to day social stress because of stigmatization. They comprise one of four minority groups (including travellers, asylum seekers and black and minority ethnic people) against whom people are most likely to express prejudice; LGB people are also among the social groups most likely to experience prejudice and discrimination (Stonewall, 2003). Perceived discrimination is associated with detrimental effects on mental health and quality of life, including self-esteem and social support (Mays and Cochran, 2001). Homophobic bullying is a persistent problem in schools; the word ‘gay’ is one of the most frequent terms of abuse in school playgrounds. Experiences of bullying, as well as not having someone to talk to, can have an impact on young LGB people's mental and physical health. Awareness of experiences of discrimination and oppression underpin the rationale for this curriculum statement and make it important that GPs have an understanding of the social context for equality and diversity in health care.

People who cross contemporary cultural boundaries of gender are known as trans people. The term trans refers to transsexual, transgender and intersex people. Trans people may be heterosexual, lesbian, gay or bisexual; they may be disabled, old or young or from black and minority ethnic communities. Trans people often meet with prejudice, discrimination and harassment in their everyday lives. They may be at risk of alcohol problems, mental health problems, self-harm and violence. Research showed that 20% of trans people reported that their health care was affected or refused altogether by GPs and other medical professionals who knew they were trans (Whittle et al., 2007). GPs who would like to offer more support felt unable to do so through lack of training and information (Department of Health, 2008) (see Box 1).

Knowledge of health issues affecting LGBT communities

Until recently, many GPs believed they did not have LGBT patients on their practice list (McNair, 2003); there is now increasing recognition of LGBT people as patients. Knowledge of the different health needs of LGBT patients is an important prerequisite for the delivery of appropriate and effective health care and in reducing morbidity. Specific health needs exist in relation to mental health, health behaviours (smoking, alcohol and substance misuse), cervical screening, breast cancer and eating disorders.

LGB people are at higher risk of suicidal behaviour, mental disorder and substance misuse and dependence than heterosexual people (King et al., 2008). Evidence suggests that there is a 4-fold higher risk of suicide attempts over a lifetime in gay and bisexual men. Depression, anxiety, alcohol and substance misuse are at least 1.5 times more common in LGB people; lesbian and bisexual (LB) women are at particular risk of substance abuse.

People who smoke are at greatest risk for coronary heart disease/cardio-vascular disease; smoking is also implicated in the development of cancers such as lung, colon and cervical cancers. Estimates from the American Cancer Society suggest that a higher proportion of LGB people are smokers compared to the general population. Current figures put smoking rates at between 41 and 25% among lesbians and gay men. Among LGB communities, evidence indicates a higher rate of alcohol consumption than the general population, as well as greater levels of difficulties related to alcohol consumption.

It is important that LB women are offered cervical screening; 19% of women who have never had heterosexual intercourse have the human papilloma virus (HPV) infection, which may lead to cervical cancer (Marrazzo et al., 2001). Evidence suggests that some GPs advise LB women that they are not at risk of cervical cancer and, consequently, they are not eligible for screening. Health promotion material to enable LB women to make an informed decision about their risk should be routinely made available by health authorities. Breast cancer may be more prevalent among LB women than their heterosexual counterparts (Valanis et al., 2000). Risk factors include not having children, alcohol consumption and inadequate screening. Among women with breast cancer, heterosexual women report greater satisfaction with their doctor's care and with the inclusion of their partner in treatment decisions.

Gay men are at greater risk for eating disorders in comparison to other men in the population. They are more likely to engage in recurrent binge eating and purging; gay men's body dissatisfaction is related to thinness and muscularity. Increased muscularity is believed to offer protection from physical attack (Kaminski et al., 2005). The American Cancer Society estimates that gay men are at increased risk for anal cancer.

Research suggests that LGB people more frequently report acute physical symptoms and chronic conditions than heterosexual people and have an increased risk for mental health problems. Knowing about these specific health issues enables a good doctor to make the care of their LGBT patients their first concern (see Box 2).

Effective skills in communicating with LGBT patients

Effective communication skills contribute to establishing trust in the patient-doctor interaction. Encourage disclosure of sexual orientation by the use of appropriate language, assurances of confidentiality and in sexual history taking. Questions that use inclusive terms will facilitate safe disclosure. Gender-neutral language such as ‘Who do you live with? Have you a partner?' will allow the patient to tell you the gender of their partner. To LB women ‘Are you sexually active? Do you need to use contraception?’ are more likely to put your LB women patients at ease than questions such as ‘Are you using contraception? Why not?’ Rather than assume a baby has a ‘daddy’, use the term ‘parent’. Direct questions such as ‘Are you gay/lesbian?’ may not elicit the intended response unless it is clear why the question is being asked and the potential benefits explained to the patient. Positive outcomes include increased likelihood of being satisfied with the care received, greater ease in communication and the possibility of including their partner in treatment regimes. Many LGB people are used to hiding their sexual orientation and often do not see its relevance to their health concern. Holistic approaches to health recognize that social context, life circumstances and networks of support are key to promoting health and well-being.

Although the doctor-patient relationship is the focus of general practice, teamwork is central to effective health care delivery. It is important that all members of the general practice team, including practice nurses, receptionists and allied health professionals, are aware of effective communication skills with LGBT patients. Reception and other staff should be included in equality and diversity training in sexual orientation. Creating a LGBT-friendly practice environment by posters and health promotion materials can help to make LGBT patients feel comfortable discussing their health concerns. Displaying a policy statement in a waiting room, which explicitly demonstrates a commitment to promoting fair treatment and valuing diversity, can establish a welcoming atmosphere (see Boxes 3 and 4).

Developing appropriate attitudes

Early research among gay and bisexual men found that GPs were sometimes seen to be unsympathetic and the men reported inappropriate or insensitive comments. In primary care, health care professionals usually, or always, presumed a patient was heterosexual. Recent findings suggest that some GPs are embarrassed or uncomfortable in providing care to LGB patients. Expectations of discomfort or embarrassment may lead to delay in seeking health care by LGB patients.

Attitudes are fundamental to the qualities needed for a good doctor. In addition to knowledge and skills, GPs must develop appropriate attitudes and behaviour. Values underpin good medical practice: patients should be treated with respect whatever their life choices and beliefs. Ethical treatment means that doctors must not allow their personal beliefs to adversely affect the professional relationship, including views about sexual orientation. If there is a conflict between a doctor's religious or moral belief and a patient's treatment need, this must be explained and the patient has the right to see another doctor [General Medical Council (GMC), 2006].

In order to develop effective and inclusive services for LGBT communities and to bring about change in an organization's culture and ethos, positive attitudes and values are needed. Vital Connection 2000 , the National Health Service (NHS) equalities framework, identifies this as an emotional process and considers ways to engage the heart. This may involve challenging or reconsidering taken for granted beliefs. Heterosexism (see Key points for definition) is pervasive in the wider culture and the delivery of health care. Valuing diversity means, for example, that if a patient comes out as lesbian, gay or bisexual, this is not ignored or forgotten about by the GP but rather it is seen as an opportunity to provide relevant health information and for the expression of positive attitudes and behaviour. Attitudes about LGBT patients should take account of the context of their lives. LGBT patients can only be fully involved in decisions about their care if they do not feel the need to hide their sexual orientation. Their relatives and carers can only engage in their treatment and care if they are acknowledged and included as next of kin (see Box 5).

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Policy and legislative developments relating to health care delivery

The GMC has published guidance for the protection of LGB people as patients (GMC, 2007). In addition, it requires that doctors must understand a range of social and cultural values and recognize the need to make sure they are not prejudiced towards patients, including LGBT people (GMC, 2003).

Current developments offer possibilities for improvement in the health of LGBT people. Knowledge of these enhances the GP's ability to keep abreast of legislative and policy changes. The introduction of the Equality Act (Sexual Orientation) Regulations 2007 prohibits discrimination in health services. Equal treatment means that LGBT people cannot be refused care or receive a lower standard of health care. Similar protection was extended to trans people by the Sex Discrimination Regulations 2008, which made it unlawful to discriminate against transsexual people in the provision of health care. In addition, the Gender Recognition Act (GRA) 2004 provides formal recognition of the acquired gender of someone holding a Gender Recognition Certificate. The GRA 2004 brings new responsibilities to maintain client confidentiality unless the disclosure is made to a health professional for medical purposes. This applies to word of mouth disclosure and paper and computer records. A patient's gender history or treatment should be regarded as sensitive information.

The Department of Health in England and Wales is working to promote inclusive services and reduce health inequalities for LGBT people (Fish, 2007); sexual orientation is included in current efforts to mainstream equality and diversity in health care (i.e. Pacesetters Programme, www.dh.gov.uk/en/Managingyourorganisation/Equalityandhumanrights/Pacesettersprogramme/DH_078616).

The NHS equalities and diversity framework, The Vital Connection 2000 , outlines the process by which organizations can establish a connection between the communities served, services provided and the people who deliver the service. Developing the knowledge, skills and attitudes outlined in this article will contribute to these endeavours for lesbian, gay, bisexual and trans patients (see Box 6).