Abstract
Equality and diversity lie at the heart of current UK health priorities. They are important subjects for everyone who works in the National Health Service (NHS). This is particularly the case for the GP, whose role is located at the interface between the NHS and the community he or she serves. The patient-doctor relationship is crucial to the health status and health care experiences of local people; a number of whom are likely to be lesbian, gay, bisexual or trans (LGBT) people. To achieve the optimal outcomes from such encounters, the skilled GP understands the social context in which LGBT people live their lives, is knowledgeable about LGBT health concerns, is a skilled communicator with LGBT patients and has developed attitudes which value diversity. This article examines current evidence about the health needs of LGBT communities and identifies ways to support GPs to promote equality and value diversity for LGBT patients.
The GP curriculum and promoting equality and valuing diversity
Promoting equality and valuing diversity is included in section 3.4 of the Royal College of General Practitioners curriculum statement. Equality is described as ‘creating a fairer society where everyone can participate and has the opportunity to fulfil their potential’. The definition for diversity ‘is about the recognition and valuing of difference in its broadest sense. It is about creating a working culture and practices that recognise respect, value and harness difference for the benefit of the organisation and the individual including patients'.
The learning outcomes in the curriculum statement identify the importance of the social context to health and illness and of acknowledging difference. Outcomes are less specific in relation to sexual orientation than for other diversity groups: no relevant texts or resources are identified. Elsewhere, it is argued, there is a dearth of teaching about sexual orientation in undergraduate and post-qualifying medical curricula (McNair, 2003). Moreover, comparatively little attention has been devoted to lesbian, gay, bisexual or trans (LGBT) health in research, academic and professional journals or health care delivery. This article seeks to meet this gap in the knowledge base about sexual orientation equality and diversity; it will consider how GPs can integrate appropriate knowledge, skills and attitudes for the benefit of theirLGBT patients and identify appropriate resources to support them to achieve this.
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.
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).
Understanding the social context for LGBT communities
LGBT people are not an homogeneous group
They are among the social groups most likely to experience discrimination
Homophobic bullying is a persistent problem in UK schools
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).
Promoting equality: Knowledge of LGBT health issues
Develop knowledge base of LGB resources both locally and nationally in order to signpost patients to other support
Mental health problems, such as anxiety and depression, are an increased risk for some LGBT people
Suicide ideation and attempts are more common among gay and bisexual men
A higher proportion of LGB people are smokers in comparison to the general population
LB women are at risk of cervical cancer even if they have never had sex with men
Gay men are at greater risk for eating disorders than other men
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).
Effective communication with LGB patients
Encourage disclosure of sexual orientation
Use gender-neutral language
Develop awareness of potential benefits of disclosure
Maintain confidentiality
Create a LGBT-friendly practice environment
Include reception and other staff in equality and diversity training
Include sexual orientation and gender identity in policy statements
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.
Effective communication with trans patients
Trans people report that health care professionals
Persist in using male pronouns rather than female pronouns or vice versa
Are critical of their appearance or style of dress
Ask for their ‘real’ name
Good communication includes:
Using the name and title that the person transitioning deems correct
Using transsexual as a descriptive term, i.e. transsexual people or someone who is transsexual
Avoiding the terms disorder (as in gender identity disorder) or disease
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).
Valuing diversity: attitudes and behaviour towards LGBT patients
Valuing diversity in relation to LGBT patients means being able to provide relevant health information and to express positive attitudes and behaviour
Demonstrate respect for LGBT patients
Positive attitudes entail considering the ways that heterosexism underpins health care delivery
Respect the right of LGBT patients to be fully involved in decisions about their treatment and care
Recognize the obligation to consult with LGBT patients' relatives and carers
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).
Resources for GPs working with LGBT patients
British Medical Association (2005). Sexual orientation in the workplace. Available from: www.bma.org.uk
Cancer facts for lesbian and bisexual women — American Cancer Society. Available from: www.cancer.org/downloads/COM/CancerFactsfor%20Lesbians03.pdf
Cancer facts for gay and bisexual men - American Cancer Society. Available from: www.cancer.org/downloads/com/gay%20men%20cf%20brochure.pdf
American Cancer Society (ACS) (2003) Tobacco and GLBT community. Accessed via www.cancer.org/downloads/com/gay%20men%20cf%20brochure.pdf [date last accessed 13.07.2009]
General Medical Council (2007) Protecting patients: your rights as lesbian, gay and bisexual people. Available from: www.gmc-uk.org/concerns/printable_documents/stonewall_flier_english.pdf
NHS Leicester City (2009) In the Pink: Providing excellent care for LGB people, a practical guide for GPs and other health practitioners. Available from:
Prescription for Change: Lesbian and bisexual women's health check. www.stonewall.org.uk/documents/prescription_for_change_1.pdf
RCN (2005). Not Just a Friend. Available from: www.unison.org.uk/file/B1287.doc
Terence Higgins Trust (2007) GPs and gay men: 10 things to discuss with your gay and bisexual clients. Available from: www.tht.org.uk
Key points
Sexual orientation is commonly used to refer collectively to LGB people
Gender identity refers to trans people
Heterosexism is a belief system which
values heterosexuality as superior to homosexuality,
assumes that everyone is, or should be, heterosexual, and
intersects with other forms of oppression such as racism and sexism.
