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Pride in Practice: Supporting LGBT patients in primary care

Park View GP

 

Nationwide data and research has found that the lesbian, gay, bisexual and trans[i] (LGBT) community delays making appointments with their GPs, and that LGBT people are disproportionately affected by conditions including eating disorders[1], mental illness[2], and drug and alcohol use[3]. Evidence suggests that LGBT people are at increased risk of preventable premature mortality[4]. We also know that:

  • 1 in 4 LGB people are not out to any health professionals[5]
  • LGB patients are twice as likely to report they have no trust or confidence in their GP[6]
  • If LGBT people have experienced discrimination at any point, their fear of further discrimination will often prevent them from speaking out[7]

 

Homosexuality was still listed as a mental illness by the World Health Organisation until 1990 and conversion therapy was offered on the NHS up until 1980. Dr. Rafik Taibjee, former Chair of GLADD, the Gay and Lesbian Association of Doctors & Dentists, said that in 2013 he was still hearing about people being encouraged to access conversion therapy because of their sexual orientation and/or gender identity. This means that even though research demonstrates that LGBT people are more likely to experience mental ill health, those from the LGBT community are often fearful about disclosing mental ill health to their GP.

Evidence shows that LGBT people are more likely to experience cancer risk factors including smoking, problematic alcohol use and poorer diet and exercise.[8] However LGBT people are also less likely to access routine screening. Research done on lesbian and bisexual women’s experiences of cervical screening found that 40% of women in the study had been told they did not require a test due to their sexual orientation. This directly resulted in over half of them disengaging from screening programmes, believing they were not at risk. 14% of the participating women had either been refused a test or actively discouraged from having a test by a healthcare professional.[9] This may be due to changes in best practice guidelines – before we understood as much as we do now about HPV transmission and the link between HPV and cervical cancer, women who were not having sex with men were thought to not be at risk. This is based on a few prevalent myths: that HPV cannot be passed on through sexual contact between women; that women who have sex with women don’t have penetrative sex; and that there are no women with penises. However, we now know that these are myths and that anybody with a cervix who is sexually active is at risk and should be screened.

Many trans people are missed out of routine screening altogether. Trans men, regardless of whether they’ve had any genital surgery or not, will not be on the national recall for cervical screening due to being registered as male with their GP. And even those trans men who have had chest reconstruction surgery will have some remaining breast tissue putting them at risk for breast cancer. Trans women who have had genital surgery may be unaware that they might still need to access prostate screening. Non-binary people may be less likely to engage with screenings if it means being referred to as their sex assigned at birth or having to be in a vulnerable position with health professionals who might be using the wrong name or pronouns to refer to them

LGBT people are also less likely to engage with other health promotion activities, from flu vaccinations to smoking cessation services. Speaking about Stoptober, one gay man said, ‘I didn’t smoke at school. I started aged 17 when I met a guy I fell in love with and initially only smoked with him (in secret). So I had two secrets I was hiding from my parents, being gay and being a smoker. At the time I felt I was in control, I could go without having a cigarette for ages but at university I smoked more and I was struggling with my sexuality. My smoking increased the more I worried about the possible judgement I would get about me being gay from my parents, friends, society etc. The years rolled by and by the time I was in my thirties I couldn’t stop smoking. I tried about seven or eight times to quit but always went back to the perceived security of a cigarette after a month. I did access a smoking cessation service but I didn’t feel that it spoke to me as a gay man. Nothing contextualised the issue of being gay and being a smoker or recognised that smoking had a link with my anxieties about coming out, about being gay.’

So what can we do to make primary care services more accessible to LGBT people? Well, some of the changes we can make are very easy. LGBT people often look out for visible signs that a service is inclusive – these can include posters depicting LGBT people or rainbow stickers or flags. Putting a poster up might seem like something that cannot make a huge difference, but that was not the case for this gay man from Rochdale; “I was struggling to come to terms with my sexuality…Things were very dark and I was thinking of ending my life…I remembered noticing my GP Practice had a poster promoting [LGBT] Foundation’s helpline. I thought that if they are displaying the poster maybe this is somewhere I can talk about my sexuality with confidence, that I would not be met with disgust and further rejection. I nervously raised the topic with my GP and to my delight they were so supportive! They supported me through my coming out process. I felt a weight had been lifted! I now have the confidence to be out and proud… I feel like I am the person I should be, and I now have excellent mental health. I wouldn’t have had the confidence to speak to my GP without the poster being up. I am encouraging every GP Practice to have a poster displayed prominently: it could change the life of someone else like me.”

Monitoring sexual orientation and gender identity can help you identify whether LGBT people are using your services, and whether they are rating them as highly as straight and cisgender people do. It also immediately demonstrates that you have considered that LGBT people will be using your service and thought about including them; often just seeing the monitoring question will make someone feel more at ease and able to be open and honest about their life. Although it can sometimes feel embarrassing to ask someone about the gender of their sexual partners, their sexual orientation or their gender identity, it’s worth remembering that this is because of the stigma and discrimination faced by LGBT people in society and not because being lesbian, gay, bisexual and/or trans is inherently embarrassing.

Asking inclusive questions during consultations can also make a big difference to someone feeling accepted and able to be themselves. For example, asking, ‘are your sexual partners men, women, or both?’ when taking a sexual history creates an opportunity for someone to disclose their sexual orientation or a same gender partner without having to correct an incorrect assumption of heterosexuality. Making sure that you check what relationship exists between your patient and the person who has just accompanied your patient into a consultation can save a lot of awkwardness – more than once, a same gender partner has been presumed to be a sibling, or worse, the parent of a patient!

Being aware of specialist LGBT services, such as helplines, cancer support groups and domestic violence organisations can make the world of difference to your LGBT patients. A patient who has been through conversion therapy may have concerns about being referred to a mainstream counselling service, but may find the support that they need through a specialist LGBT counselling service. Letting patients know that their sexual orientation and/or gender identity is not something they have to leave at the door will go a long way to building better relationships between them and their health professionals, and improving their health outcomes in the long term.

Pride in Practice is a quality assurance and support service that strengthens and develops your relationship with your lesbian, gay, bisexual and trans patients. For more information about Pride in Practice or about lesbian, gay, bisexual and trans patients’ needs, visit http://lgbt.foundation/prideinpractice or email pip@lgbt.foundation

[1] Guasp, A. (2012). Gay and Bisexual Men’s Health Survey: North West

[2] McNeil, J. et al. (2012). Trans Mental Health Study

[3] Buffin, J. Roy, A. Williams, H. and Winter, A. (2011). Part of the Picture: Lesbian, gay and bisexual people’s alcohol and drug use in England 2009 – 2011

[4] Williams, H. et al. (2013). The Lesbian, Gay, Bisexual and Trans Public Health Outcomes Framework Companion Document

[5] NHS Wirral, (2012). Wirral’s Lesbian, Gay, Bisexual and Trans Needs Assessment

[6] 2014 National GP Survey

[7] Herda, D. (2013). Heterosexual Masculinities, Anti-homophobias, and Shifts in Hegemonic Masculinity in Sociological Perspectives

[8] LGBT Foundation. (2014). Greater Manchester Building Health Partnerships Summary Report

[9] Light B and Ormandy P. (2011). Lesbian, Gay and Bisexual Women in the North West:  A Multi-Method Study of Cervical Screening Attitudes, Experiences and Uptake, University of Salford Report.

[i] Trans is an umbrella and inclusive term used to describe people whose gender identity differs in some way from that which they were assigned at birth; including non-binary people, cross dressers and those who partially or incompletely identify with their sex assigned at birth.

Guest Blogger: Laurence Webb –  Pride in Practice Co-ordinator

Picture: Park View Medical Centre, Manchester receiving their GOLD Pride in Practice award

 

 

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The Paracetamol Debate

So what’s all the fuss about paracetamol? And should we be using it in the management of OA.

Controversy emerged regarding the use of paracetamol in the management of OA a while back when NICE were drafting their new guidelines.

At the time they warned of the potential side effects of paracetamol and said it has ‘limited benefit’.

NICE warned GPs against prescribing paracetamol for patients with osteoarthritis after its experts said they were ‘extremely concerned’ about the links of higher doses to cardiovascular, gastrointestinal and renal adverse events.

When used, it should be the ‘lowest effective dose’ for the ‘shortest possible time’ and clinicians should be particularly cautious of using it in combination with an oral NSAID, the guidance added.

The Guidance Development Group felt that the increase in renal adverse events with long-term cumulative doses of paracetamol particularly would be a surprising finding for most clinicians and wished to highlight this issue.

Shortly afterwards NICE was forced into a U-turn on its previous advice not to routinely prescribe paracetamol in patients with osteoarthritis, following criticism that the recommendation would have a drastic impact on GP analgesia management.

The dramatic change came after medicines regulators disagreed with NICE’s concerns about patient safety and experts said the move to other analgesic options such as opioids could put patients at greater risk.

See the full NICE guidance on OA here. The clear message is that we should be focusing our attention on physical treatment instead. These may be more difficult to sell to our patients but are far more likely to provide both better analgesia and better functional outcomes than medications.

Try directing some of your patients to Arthritis Research UK website where they can find information on Exercises to Manage Pain.

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Junior Doctors’ Strike

Junior Doctors went on strike this week resulting in over 3,000 operations being cancelled nationwide.

Patients were urged to see their GPs instead of attending hospital.

NHS England said about 10,000 junior doctors had reported for duty out of 26,000 scheduled to work the day shift on Tuesday – although many of those had agreed in advance to come in to make sure emergency cover was provided and others were not members of the BMA.

The action came after the BMA and the government failed to reach agreement on a proposed new contract for junior doctors.

The BMA, which is concerned about pay for weekend working, career progression and safeguards to protect doctors from being overworked, said the strike had sent a “clear message” to the government.

However, Health Secretary Jeremy Hunt described the walkout as “completely unnecessary” and urged junior doctors to return to the negotiating table.

Officials from Acas (Conciliation service) said they would hold discussions with both sides, although government sources said they were still prepared to impose the contract if the deadlock could not be broken.

Danny Mortimer, chief executive of NHS Employers, which represents the government in contract talks, said he hoped that would not happen.

“I’m really hopeful that when the BMA return to the talks we can give junior doctors more confidence in both the pay offer that we’re putting to them, but also the improved protections we want to put in place around their safety.

“I am desperate to avoid another repeat of industrial action at the end of the month. It’s not in their interest and it’s not in the interest of patients.”

The next proposed strike is a 48-hour one beginning on 26 January.