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Tackling homophobia in primary care

Laurence Webb, Pride in Practice co-ordinator, has some tips and strategies for general practice to improve health outcomes among LGBT people, and explores some common misunderstandings and stereotypes.

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

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

So how do we tackle homophobia, or perceptions of homophobia, within general practice? How do we ensure that our practices are open and welcoming to lesbian, gay, bisexual and trans patients? 

One way of doing this is to get involved in Pride in Practice, a quality assurance service for GP practices and their LGBT patients. The following are some of the experiences I’ve had delivering Pride in Practice, and some of my tips for making sure that your LGBT patients are receiving the best possible care when they visit your practice. 

Sexual orientation monitoring 

Many practices already carry out routine monitoring of some protected characteristics, such as the age, gender and race of their staff and patients. Protected characteristics are the nine characteristics protected from discrimination under the Equality Act 2010: 

• Age
• Disability
• Gender reassignment
• Marriage/civil partnership
• Pregnancy and maternity
• Race
• Sexual orientation
• Religion or belief
• Sex 

‘All my patients are Arab and therefore not gay’ 

Although these characteristics do not define an individual, studies have shown that they will have an effect on their health outcomes. Monitoring is vital in understanding any barriers to services that may exist and safeguarding against discrimination. Many of the negative experiences that LGBT people have had when accessing their GP practice could have been avoided if their needs were better understood. A practice manager in a busy city-centre practice who did not monitor sexual orientation once said to me: “All my patients are Arab and therefore not gay,” despite the fact that many Arab people are LGBT, and that LGBT people from ethnic minority backgrounds often experience greater health inequalities and overall poorer health outcomes than their white counterparts. 

‘How embarrassing!’ 

One barrier that health professionals regularly come up against when asking someone about their sexual orientation, is that it can feel like a rude or overly personal question, which people imagine is akin to asking someone about their sex life. This can, understandably, be embarrassing, especially when you are not quite sure how to ask these questions and are worried about causing offence! It’s important to remember that the reason talking about sexual orientation seems embarrassing is because of the stigma and discrimination towards LGB people, and not because they are inherently embarrassing topics. 

Asking someone about their sexual orientation is no different to asking someone

whether they have children, if they are married, or how old they are – you are simply asking someone about a part of their life which may affect their health so that you have all the information that you need to be able to offer them the highest possible standard of care. 

‘It’s not about stereotyping, but bringing things to the forefront of my mind, such as signposting specific services’ 

Some of the reported benefits of monitoring sexual orientation and gender identity are faster and more efficient consultations, more appropriate use of services, and more holistic, person-centred care. It can enable clinicians to offer their patients a choice between a mainstream or LGBT-specific service. For example, signposting someone to domestic abuse services can sometimes be more complicated in same-sex relationships. Among the reasons for this is the fact that perpetrator and victim can get access to the same refuge, and unfortunately services not targeted at LGBT people may not take incidents of domestic violence between partners of the same gender as seriously as incidents of domestic violence within heterosexual relationships. 

Health promotion 

‘I was told nuns don’t get cervical cancer – to which I responded that I wasn’t exactly a nun!’ 

Effective demographic monitoring can also be important to enable LGBT patients to engage in health promotion activities, such as routine screening programmes. Trans people specifically are often missed out of routine screening programmes and may not be given the information they need to be able to be proactive about their own health. 

For example, many trans men who have not had a hysterectomy or who have had a partial hysterectomy have never had a cervical screening and are not aware they need one, and trans men are more likely to have an inadequate sample when they do access cervical screening. 

Lesbian and bisexual women are almost 10% less likely to access cervical screening than heterosexual women, and 14% of lesbian and bisexual women report being refused a cervical screen or discouraged from having a test by a healthcare professional due to their sexual orientation, being told things like ‘nuns don’t get cervical cancer’. This is likely due to prevailing myths that HPV cannot be transmitted between women and that women who have sex with women do not have penetrative sex. 

Inclusive language 

Often patients don’t know how or when to come out as lesbian, gay or bisexual to their clinicians and this can lead to them withholding all kinds of relevant information. It’s important that all staff are aware of the importance of inclusive language – for example, if a male patient comes in to reception to collect his partner’s prescription, the receptionist asking ‘what’s your partner’s name?’ rather than ‘what’s her name?’ will make a big difference to how supportive and welcoming your practice seems to a gay or bisexual man. 

‘I am sexually active but I don’t need the contraceptive pill!’ 

Lesbian and bisexual women often have the frustrating experience of having their GP regularly assume that because they are of childbearing age, they need to be on the contraceptive pill to prevent pregnancy. 

While the instinct to try to ensure that all women have access to contraception should they need it is admirable, many lesbians find this assumption about their sexual orientation makes them feel unable to be open and honest with their GP about their sexual behaviour and any consequent health needs. It can make them feel that the onus is on them to come out, rather than on their GP to ask questions about sexual orientation and sexual behaviour in an inclusive way.

‘That was the most informative and important visit to the GP I’ve ever had’ 

Monitoring for sexual orientation is key to understanding the needs of your patient population, but it is worth remembering that sexual orientation is not always consistent with sexual behaviour. 

At a practice that monitored sexual orientation, a patient who identified himself as straight had never been asked about the gender of his sexual partners in the many years he had been registered there, because it was assumed that, being a straight man, all his partners were women. 

However, during an appointment with a nurse who was new to the practice, the patient was asked inclusive questions about his sexual history, including ‘are your sexual partners men, women, or both?’, and answered ‘both’. The patient did not identify himself as gay or bisexual because he did not have romantic relationships with men, but he did have male sexual partners. The patient disclosed that he was struggling to negotiate safer sex with men, and the nurse discovered that there were gaps in his knowledge and was able to give him his Hepatitis B vaccinations, advise him about contraception and safer sex, and encourage him to have regular HIV tests. 

About Pride in Practice 

Pride in Practice is a quality assurance and support service that strengthens and develops practices’ relationships with their lesbian, gay, bisexual and trans patients.

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