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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