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Sexual orientation in the workplace

June 2005

Doctors’ responsibilities towards patients
Provision of goods and services
The Employment Equality (Sexual orientation) Regulations 2003 do not cover the provision of goods and services. The equitable treatment of patients, however, is of the utmost importance. The GMC provides the following guidance to doctors about their duty to treat patients.

Relationship with patients
Doctors should respect patients ‘regardless of their lifestyle, culture, beliefs, race, colour, gender, sexuality, disability, age, or social or economic status’. Graduates ‘must understand a range of social and cultural values, and differing views about healthcare and illness. They must be aware of issues such as alcohol and drug abuse, domestic violence and abuse of the vulnerable patient. They must recognise the need to make sure that they are not prejudiced by patients’ lifestyle, culture, beliefs, race, colour, gender, sexuality, age, mental or physical disability and social or economic status’. [Go to reference 30]

‘The investigations or treatment you provide or arrange must be based on your clinical judgement of patients’ needs and the likely effectiveness of the treatment. You must not allow your views about patients’ lifestyle, culture, beliefs, race, colour, gender, sexuality, disability, age, or social or economic status, to prejudice the treatment you provide or arrange. You must not refuse or delay treatment because you believe that patients’ actions have contributed to their condition’. [Go to reference 22]

Source: General Medical Council (2001, 2003)

Healthcare needs and promotion
Many lesbian, gay and bisexual patients avoid or delay seeking care because of concerns about attitudes or due to real or perceived discrimination. Medical settings need to be sensitive to this. A social research group specialising in sexual health and aspects of lesbian, gay and bisexual health and wellbeing, surveyed gay and bisexual men about their experience of using primary care services. [Go to reference 31] This research found that gay men are often reticent to disclose their sexual orientation to their GP for a range of reasons including fear of negative reactions or breaches of confidentiality, and worry that the subject is not relevant to the consultation. Patients consulting their doctors for purely physical problems may not feel the need to ‘come out’ to their doctor but those wishing to have an ongoing relationship with their doctor often feel it important that they can be honest about their relationships. [Go to reference 31]

To ensure that all patients receive the best care possible, patients must feel comfortable being open about their sexual orientation with their doctor, when appropriate. Paying attention to certain aspects of the doctor-patient communication can help this. Doctors need to maintain gender-neutral language when referring to partners, and avoid simply asking whether patients are married. For example, if a patient mentions a partner, rather than automatically using ‘he’ or ‘she’, which indicates heterosexuality, there is the option of using ‘they’. Patients are more likely to ‘come out’ if they feel that the doctor has not made an assumption. It is not recommended practice to ask patients directly about the sex of their partners if it is not relevant to the consultation, so that the choice to ‘come out’ is left to the patient. Doctors also need to appreciate that there can be a difference between how patients identify themselves and their sexual behaviour, for example, a married man who identifies as heterosexual, who however has sex with other men as well as his wife.

Personal anecdote
‘As a lesbian I learnt the hard way how difficult it can be as a patient, when doctors and other hospital staff assumed I was heterosexual. Before my emergency operation, the only question I was asked about a relationship was “Are you married?”. I had to assert myself in order for them to accept my female partner’s telephone number as a contact. It would have been easier not to have bothered, as I didn’t feel my relationship was acknowledged or accepted.’
Source: Anonymous (2005) personal communication

Effective communication skills are essential and every general practice should ensure that patients know that they will be treated equally and with respect by all staff regardless of sexual orientation. The report based on the survey of gay and bisexual men recommended several steps for increasing the acceptability of GP services to gay men. [Go to reference 31] These steps are equally applicable to the hospital setting:

- increase all clinic staff’s capacity for meaningful communication with patients

- require all GP practices to develop and prominently display equality policies, statements and guidelines, which explicitly include sexual orientation

- require all GP practices to adhere to clear guidelines around confidentiality and patient notes and to make those guidelines clear to patients

- require all staff to act according to these guidelines.

Further guidelines for working with lesbian, gay and bisexual patients
Small effort, big change: A general practice guide to working with gay and bisexual men (2001) [Go to reference 32] provides some examples of how staff can address concerns of gay patients. It suggests that the provision of guidelines for staff can help in addressing concerns of patients, by increasing staff awareness, understanding of sexual health issues and knowledge of referral services and in identifying staff training needs. Examples of further guidelines for working with lesbian, gay and bisexual patients include:

- PACE has published guidance based on the new National Service Framework for mental health in England. Informed by research, the guidance provides advice to ensure good practice in working with lesbian, gay and bisexual patients in mental health. [Go to reference 33]. It covers many areas, such as appropriate use of non-discriminatory language and revising the National Service Framework standards to be more inclusive. PACE also provides services to the lesbian, gay and bisexual population in the greater London area.

- Working with lesbian, gay and bisexual (LGB) people in mental health: a model for change (2003) [Go to reference 34] provides another framework covering assessment of training, knowledge, practice, policies and procedures and developing provision.

- Towards a healthier lesbian, gay, bisexual and transgender Scotland (2003) [Go to reference 35] is a report on the health and wellbeing of lesbian, gay, bisexual, and transgender individuals in Scotland. It addresses specific health concerns such as the necessity of screening for certain types of cancers, mental health needs as a result of prejudice and discrimination, addiction, sexual health, HIV, and eating disorders.

Sexual health promotion is only one component of the health needs of lesbian, gay and bisexual patients. Healthcare professionals should be careful not to reinforce stereotypes by assuming that sexual health is the most pressing health need of gay patients. Research has shown that gay men and lesbians have been found to be more likely to have consulted mental health professionals in the past, deliberately harmed themselves or used recreational drugs. [Go to reference 36] It is felt that internalising homophobia from a hostile society can be an important contributory factor for some. It is important, however, that clinicians do not automatically attribute a patient’s mental health problem to their sexual orientation but rather assess each person as an individual.

In relation to the healthcare of gay and bisexual men, the provision of sexual health services still receives the most attention. Lesbians and bisexual women, however, are a less visible group in healthcare. Evidence shows that lesbians are more likely to be overdue for cervical screening than heterosexual women. [Go to references 37,38]. This group could be specifically targeted when chasing-up those who do not attend for smears. This could be done by a standard letter to all those who do not attend for smears, which includes the information that lesbians can still develop cervical carcinoma and should also attend screening. Some lesbians choose to attend lesbian-friendly gynaecology clinics as they have experienced their own doctors making the assumption that they are heterosexual and they feel uneasy about ‘coming out’. Doctors should therefore be careful not to make assumptions but ask women ‘if’ they have a need for contraception.

The UK departments of health have published guidance about healthcare promotion for patients with a variety of sexual health needs. [Go to reference 39]. Some suggestions are:
- re-name ‘family planning clinic’, for example, ‘sexual health clinic’ or ‘sexual health and wellbeing clinic’ are more responsive and inclusive terms

- use the term partner rather than boyfriend or girlfriend, which acknowledges an understanding and attitude that someone may be involved with a same sex partner

- consider having positive images of gay men and women on display in appropriate settings

- find out about local support groups and services

- ensure that where condoms are available, there are a variety including extra strong ones and lubricant

- do not make assumptions about your patients’ sexuality, even if they are married. [Go to reference 39].