Dr Mark Holloway summarises the RCGPNI guidance on the care of lesbian, gay, and bisexual patients in primary care

holloway mark

Independent content logo

Read this article to learn more about:

  • health issues faced by lesbian, gay, and bisexual people
  • possible strategies for improving the care of lesbian, gay, and bisexual people
  • how practices can become more inclusive.

Key points

GP commissioning messages

I n 2013, the Office of National Statistics reported that 1.6% of adults in the UK identify as lesbian, gay, or bisexual (LGB);1 however, this is likely to be an underestimation, with the true figure estimated at 5–7%. Therefore, in a practice with 5000 patients, 250–350 will identify as LGB. In light of this, it is perhaps surprising that until recently, there has been no specific UK-based guidance for the care of LGB patients in primary care.

With support from the Public Health Agency Northern Ireland, the Royal College of General Practitioners Northern Ireland (RCGPNI) has developed a guideline to help primary care health professionals provide the best care possible to LGB patients.3 It has also developed a similar guideline for transgender patients.4 The RCGPNI hopes that these guidelines will improve the care that LGB and/or transgender (LGB &/T) people receive within the health service in Northern Ireland.

The need for guidance

In a survey commissioned by Stonewall, one third of gay and bisexual men who had accessed healthcare services in the last year reported a negative experience related to their sexual orientation. The voluntary agency Here NI, which supports lesbian and bisexual women in Northern Ireland, has published reports suggesting there is considerable room for improvement in the care provided to LGB patients. The titles of their reports are thought-provoking: A mighty silence andInvisible women.6,7

Issues faced by the LGB population

Social issues

LGB people regularly experience invisibility, violence, discrimination, and prejudice, which can have a negative impact on their emotional health and wellbeing.8

Many LGB people first become aware of their minority sexual orientation and/or gender identity as a child or adolescent. The Through our minds study of the experiences of LGB &/T people in Northern Ireland found that more than 60% had been called hurtful names related to sexual orientation and/or gender identity during their school years.8

The Through our minds study also found that LGB &/T people have negative experiences in their everyday lives related to their actual or perceived sexual orientation and/or gender identity. These included threats of physical violence, and discrimination when accessing goods, facilities, or services. One third of those involved with the study said they had been threatened with being ‘outed’ at least once.8

LGB people often find social isolation a problem; for example, one study found that 41% of LGB people aged over 55 years live alone, compared with 28% of heterosexual people of the same age.9 Social isolation can affect people of all ages and can be a particular problem in rural areas.7

Mental health

LGB &/T people are at increased risk of depression, self-harm, and suicide, compared with heterosexuals. One meta-analysis showed a two-fold increase in suicide attempts by both men and women in the preceding year, and a four-fold increase in suicide attempts by gay and bisexual men over the course of a lifetime.10

It is worth noting that one Northern Ireland-based survey found that 78.2% of patients who sought help with their depression and 54.4% of those who asked for help following a suicide attempt chose to present to their GP8

Gay and bisexual men are more likely to develop eating disorders than heterosexual men. In a survey commissioned by Stonewall, 13% said they had had a problem with their weight or eating in the last year, compared with 4% of men in general.5

Being lesbian, gay, or bisexual is not a mental illness and cannot be ‘cured’. Despite this, people report that they have been subjected to ‘conversion therapy’ (also known as reparative or ‘gay-cure’ therapy). The UK Council for Psychotherapy has released a consensus statement condemning such practices.11 This is supported by the Royal College of Psychiatrists, which states: ‘The Royal College of Psychiatrists believes strongly in evidence-based treatment. There is no sound scientific evidence that sexual orientation can be changed. Furthermore, so-called treatments of homosexuality create a setting in which prejudice and discrimination flourish.’12

Substance misuse

The All partied out? survey looked at the issue of substance misuse in Northern Ireland’s LGB &/T population. It found that 44% of LGB &/T people in Northern Ireland smoked (compared with 24% of the general population), and that more than one half of LGB &/T people drank alcohol to a hazardous level.13

Illegal drug use is higher in the LGB &/T population than the general population. This disparity is highest among 15–24 year olds, which may be related to these young people coming to terms with their sexual orientation and the stress of ‘coming out’.13

There appear to be many reasons for higher substance misuse in the LGB population, with the evidence showing that it cannot be solely attributed to the ‘gay scene’ of bars and night clubs.13

LGB &/T people are also less likely to access substance misuse services, often because of worries about discrimination.13

Health screening

Lesbian and bisexual women are less likely to have had a cervical smear than women in general.14 One UK-based survey showed that 20% had wrongly been told they did not need to have a cervical smear.14

More lesbian and bisexual women aged 50–79 have been diagnosed with breast cancer than women in general, despite rates of breast screening being similar.14

Sexual health

It is a worrying finding that in one survey, 44% of gay and bisexual men reported that they had never discussed sexually transmitted infections (STIs) with a healthcare professional; however, a clinician should not necessarily automatically offer STI screening when a patient ‘comes out’ to them. Instead, it is important to take a more holistic view—high-risk sexual behaviour might indicate other underlying issues, such as deteriorating mental health, social exclusion, or substance misuse.3 The guideline recommends that GPs should only screen or manage STIs within their level of competence and should refer to genito-urinary medicine (GUM) clinics where appropriate.3

‘Chemsex’ is a term commonly used by gay or bisexual men to describe sex that occurs under the influence of drugs.15 This high-risk behaviour is becoming an increasing issue among men who have sex with men.

Patients who have had potential sexual exposure to human immunodeficiency virus (HIV) should be urgently referred to GUM for a same-day assessment. They may be eligible for a 28-day course of antiviral tablets, known as post-exposure prophylaxis (PEP) or post-exposure prophylaxis after sexual exposure (PEPSE).16

Creating an open and inclusive environment

LGB patients have specific healthcare needs, but studies suggest that they are more likely to be ‘out’ to their work colleagues, manager, friends, or family than to their GP.5 ‘Coming out’ is not a one-off event; it is something LGB &/T people have to do repeatedly during their lives. LGB patients report that healthcare professionals are often guilty of heteronormativity. Use of open questions and gender-neutral, inclusive terminology is more likely to facilitate disclosure of sexual orientation; however, non-disclosure should also be respected.3

The guideline suggests a number of ways in which a practice can demonstrate an open and inclusive environment to LGB patients, including:3

  • sexual orientation training for all primary care staff
  • use of sensitive language by reception staff
  • display of posters and leaflets reflecting LGB &/T issues in the waiting room
  • inclusion of sexual orientation and gender in the anti-discrimination policy (which should be clearly displayed).

Summary

LGB patients face a number of issues on a daily basis. Their needs in primary care are complex and go far beyond STI screening. The RCGPNI guideline explains these issues and suggests strategies to meet the specific needs of this group.

Key points

  • LGB &/T people are at increased risk of depression, self-harm, and suicide compared with heterosexual people
  • Gay and bisexual men are more likely to have eating disorders than heterosexual men
  • Being lesbian, gay, or bisexual is not a mental illness that can be ‘cured’
  • Levels of smoking, drinking alcohol, and illegal drug use are higher in the LGB &/T population but LGB &/T people are less likely to access substance misuse services
  • Lesbian and bisexual women are less likely to have cervical screening than other women and may be told wrongly that they do not need a cervical smear
  • Rates of diagnosed breast cancer are higher in lesbian and bisexual women aged 50–79 than in other women, despite similar rates of breast screening
  • Health practitioners should view high-risk sexual behaviour in a gay or bisexual man holistically
  • GPs should not screen or manage sexually transmitted infections outside their levels of competence and should refer to GUM clinics where appropriate:
    • patients who may have had exposure to HIV should be referred urgently to GUM for same-day assessment
  • LGB people are more likely to be ‘out’ to work colleagues, friends, and family than their GP:
    • using open questions and gender-neutral, inclusive terminology may help patients disclose sexual orientation but non-disclosure should also be respected
  • Practices can demonstrate an open and inclusive environment to LGB patients by:
    • providing relevant training to all staff and using sensitive language
    • displaying posters and leaflets reflecting LGB &/T issues
    • including sexual orientation and gender in a clearly displayed anti-discrimination policy.

LGB=lesbian, gay or bisexual; LGB &/T=lesbian, gay, bisexual and/or transgender; GUM=genito-urinary medicine; HIV=human immunodeficiency virus

Back to top

GP commissioning messages

  • People who identify as LGB have a higher incidence of certain illnesses (e.g. mental health), are less likely to access screening (e.g cervical smears), and are more likely to undertake substance misuse it is therefore important to identify them and offer services to help address these issues
  • General practices should encourage all staff to help make LGB patients comfortable in openly expressing their health needs without fear of discrimination
  • Local authority departments of public health are ideally placed to commission health prevention services for this group and of course support them in accessing services from which they may feel excluded
  • Effective sexual health clinics will form part of these commissioned services and can also help direct LGB people to other CCG commissioned services such as IAPT services to support mental health
  • CCGs working with local authorities should consider awareness training for LGB population health; practice teams should ideally be supported by online training modules that all staff can access easily and effectively.

LGB=lesbian, gay, and bisexual; IAPT=improving access to psychological therapies

Back to top

g logo gls turquoise

Read the Guidelines summary of the RCGPNI Guidelines for the care of lesbian, gay and bisexual patients in primary care and Guidelines for the care of trans* patients in primary care for more recommendations on the inclusive care of LGBT patients

References

  1. Office for National Statistics. Integrated household survey (experimental statistics): January to December 2013. ONS, 2014. Available at: http://www.ons.gov. uk/ons/dcp171778_379565.pdf
  2. Department of Trade and Industry. Final regulatory impact assessment: Civil Partnership Act 2004. London: DTI. Available at: webarchive.nationalarchives.gov. uk/20090609003228/http://www.berr.gov.uk/ files/file23829.pdf
  3. Royal College of General Practitioners Northern Ireland. Guidelines for the care of lesbian, gay and bisexual patients in primary care. Belfast: RCGPNI, 2015. Available at:www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z-policy/RCGPNIGuidelines-for-the-care-of-LGB-patients-inprimary-care-2015-web.ashx
  4. Royal College of General Practitioners Northern Ireland. Guidelines for the care of trans* patients in primary care. Belfast: RCGPNI, 2015. Available at: www.rcgp.org. uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z-policy/RCGPNI-Guidance-for-thecare-of-Trans-people-in-primary-care-2015-web.ashx
  5. Guasp A. Gay and bisexual men’s health survey. London: Stonewall, 2013. Available at: www.stonewall.org.uk/sites/default/ files/Gay_and_Bisexual_Men_s_Health_ Survey__2013_.pdf
  6. Quiery M. A mighty silence: a report on the needs of lesbians and bisexual women in Northern Ireland. Ballymena: Lesbian Advocacy Services Initiative, 2002. Available at: hereni.org/wp-content/uploads/2012/09/a_ mighty_silence.pdf
  7. Quiery M. Invisible women: a review of the impact of discrimination and social exclusion on lesbian and bisexual women’s health in Northern Ireland. Ballymena: Lesbian Advocacy Services Initiative, 2007. Available at: hereni.org/wp-content/uploads/2012/09/ invisible_women.pdf
  8. O’Hara M. Through our minds: exploring the emotional health and wellbeing of lesbian, gay, bisexual and transgender people in Northern Ireland. Belfast: The Rainbow Project, 2013. Available at: www.rainbow-project.org/ assets/publications/through%20our%20 minds.pdf
  9. Guasp A. Lesbian, gay and bisexual people in later life. London: Stonewall, 2011. Available at: www.stonewall.org.uk/sites/default/files/ LGB_people_in_Later_Life__2011_.pdf
  10. King M, Semlyen J, Tai SS et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry 2008; 8: 70.
  11. UK Council for Psychotherapy. Conversion therapy. Consensus statement. London: UKCP, 2014. Available at: www. psychotherapy.org.uk/UKCP_Documents/ policy/Conversion%20therapy.pdf
  12. Royal College of Psychiatrists. Royal College of Psychiatrists’ position statement on sexual orientation. London: RCPsych, 2014. Available at: www.rcpsych.ac.uk/pdf/ps02_2014.pdf
  13. Rooney E. All partied out? Substance use in Northern Ireland’s lesbian, gay, bisexual and transgender community. Belfast: The Rainbow Project, 2012. Available at: www.rainbowproject. org/assets/publications/All%20 Partied%20Out.pdf
  14. Hunt R, Fish J. Prescription for change: lesbian and bisexual women’s health check. London: Stonewall, 2008. Available at:www.stonewall.org.uk/sites/default/files/ Prescription_for_Change__2008_.pdf
  15. Bourne A, Reid D, Hickson F et al. The Chemsex Study: drug use in sexual settings among gay and bisexual men in Lambeth, Southwark & Lewisham. London: Sigma Research, 2014. Available at: www. sigmaresearch.org.uk/files/report2014a.pdf
  16. Benn P, Fisher M, Kulasegaram R. UK guideline for the use of post-exposure prophylaxis for HIV following sexual exposure. Int J STD AIDS 2011; 22:  695–708