Lifting LGBTIQ+ barriers - Medical Observer

Asking the right questions is key to providing healthcare sensitive to sexual orientation.

About 2% of Australian adults identify as lesbian, gay or bisexual. There is a spectrum of ways people define themselves and a spectrum of behaviours. Some 6-8% report lifetime same sex behaviour and 7-15% report same sex attraction.¹ These groups represent a significant percentage of the Australian population.

While all individuals should have access to quality healthcare and appropriate interpersonal and clinical care, research shows that people who identify as lesbian, gay, bisexual, trans, intersex or queer (LGBTIQ+) may experience health inequalities. These can be made worse by difficulties accessing culturally sensitive healthcare.²

Poorer mental health and suicidal behaviours are experienced by a disproportionate number of LGBTIQ+ women compared with other women. This is directly linked to the stigma, prejudice, discrimination and abuse they experience because of their sexual orientation.

Many GPs have not received training specific to LGBTIQ+ patients but they can become more informed and better equipped to do so. Patients can be reassured by simple measures such as the use of gender-neutral words on forms and in conversations, and having LGBTIQ+-friendly posters displayed in waiting rooms. In addition, sensitive inquiry regarding mental health and health checks can help to provide
appropriate care.

Barriers to care

A systematic review of the healthcare experiences of patients who identified as LGBTIQ+ women found these to be "generally poor".²

There are many reasons why this would be the case. Medical practitioners may assume a patient is heterosexual, which can affect the ability to form an effective doctor-patient relationship.

Also, many people experience a spectrum of sexuality throughout their lifetime and this must be taken into account.

Communication barriers in the form of provider discomfort, silencing of disclosure and pathologising can limit a patient's ability to have an open and honest discussion.

Other barriers include poor provider knowledge, a lack of LGBTIQ+-specific resources and referral networks, and poor health-seeking behaviours, especially with screening.

It is important to avoid viewing LGBTIQ+ as a single category, as this can hamper appropriate healthcare.

There are several different demographics, with individual histories and needs, with some overlap between groups.3

Specific LGBTIQ+ issues

Social influences:

• Despite the legalisation of same sex marriage, same sex relationships still receive a lower level of social recognition compared with heterosexual relationships, which can lead to discrimination.
• Misinformation about health issues, for example, many providers have wrongly told LGBTIQ+ women they don't require cervical screening and that can influence the likelihood of engagement with preventive activities.
• Domestic violence can be an issue: the rate is similar to that within heterosexual relationships.
• A non-biological parent in a same sex couple with children can lack legal and social recognition.
• Substance use is higher among some groups.
• Patients are more likely to have experienced child or adult sexual abuse.
• Disordered eating is more likely among bisexual women.

Biological influences:

• Conception may require medical guidance and referral.
• LGBTIQ+ women are more at risk of STIs than heterosexuals, particularly bacterial vaginosis and herpes simplex for women who have sex with women. However, women who have sex with women, and the doctors who care for them, often perceive their risk to be lower, so they are generally underscreened. LGBTI+ women need safe sex advice specific to their sexual behaviours.
• Cervical screening tests are required for all women who have ever been sexually active. HPV can be transmitted between women. In addition, many women have histories of sex with men.
• Risks for breast, ovarian and bowel cancer may be higher as a result of lower contraceptive pill use and fewer pregnancies, increased use of alcohol and cigarettes, and lower rates of screening.

Consultation

The General Practice and Primary Health Care Academic Centre at the University of Melbourne has produced an excellent guide to sensitive care for lesbian, gay and bisexual patients that is endorsed by the Royal Australasian College of Physicians.

It suggests the following:

• Facilitate an inclusive environment that serves to normalise the patient's sexual orientation.
• Avoid assumptions of heterosexuality.
• Use culturally aware language. "For example, using a gender-neutral word for partner until the gender of the partner is disclosed, using the word the person uses for their sexual orientation (lesbian, gay, bisexual, queer, not straight) and partner (significant other, companion)," the guide says.⁴

Tips for discussing sexual orientation

In general, LGBTIQ+ people expect GPs to ask about their sexual orientation and do not feel it is an invasion of privacy.

It is ideal to ask early in the GP-patient relationship. A neutral answer may mean that the person needs more time. Always assure the patient of confidentiality of anything discussed.

Conversation starters for discussing sexual orientation

Introducing the topic

• What is your social situation?
• Your symptoms could be related to your sexual history so I'll need to ask you about it.
• To ensure the best referral, may I ask how you define your sexual orientation?

Demographic questions

• Do you have a partner?
• Who do you consider your close family?
• Who is your preferred contact for emergencies?
• Are you a parent? Do you co-parent a child/children with anyone?
• If so, who is the biological parent? (Don't ask 'who is the real parent?')
• Are you comfortable if I make a note of your significant relationship in the medical record?⁵

Sexual history

• How would you describe your sexual orientation?
• Do you need any information about safer sex?
• Do you have any need for contraception?
• Do you feel safe with your partner?

To probe for discrimination-related health issues

• Have you had any negative experiences relating to your sexual orientation?

If referring to a support group

• Would you prefer a gay/lesbian/bisexual-specific or a general support group?⁴

Practice points:

Research shows that people who identify as LGBTIQ+ may experience health inequalities.

• Creating a safe space for open disclosure is easy and is key to optimising health outcomes among LGBTIQ+ women.
• Facilitate an inclusive environment that serves to normalise the patient's sexual orientation.
• Avoid assumptions of heterosexuality and establish an openly non-judgemental and accepting attitude.

Resources:

DocLIST: Medical Practitioners Recommended by Lesbian and Bisexual Women

National LGBTI Health Alliance

ACON

GLHV (Gay and Lesbian Health Victoria)

Rainbow Health Victoria