Guidelines for the Care of Lesbian, Gay, Bisexual, and Trans Patients in Primary Care

Overview

This Guidelines summary provides recommendations on the care of lesbian, gay, bisexual, and transgender (LGBT) people in primary care. For a full set of recommendations, refer to the full guidelines.

Care of LGB Patients in Primary Care

• Lesbian, gay, and bisexual (LGB) patients face minority pressure, stigmatisation, and the pressure of ‘coming out’ on a daily basis. They have higher rates of depression, self-harm and suicide. They are more likely to smoke, take alcohol to excess, and take illegal drugs. Their complex needs in primary care go far beyond sexually transmitted infection (STI) screening.

Consultation Issues

• There are a number of ways a practice can demonstrate an open and inclusive clinical environment to lesbian, gay, bisexual, and transgender (LGB and T) patients:
  • allow LGB and T patients to self-identify on new patient enrolment forms if they choose to do so
  • practices could consider how they record or code that patients are LGB and T after gaining consent to do so from the patient
  • reception staff should demonstrate positive attitudes and use sensitive language
  • sexual orientation training could be considered for all primary care staff
  • posters and leaflets reflecting LGB and T issues can be displayed in the waiting room
  • sexual orientation and gender should be included in the anti-discrimination policy and it should be clearly displayed
  • include LGB and T patients in patient participation groups
• During a consultation, it is important not to make assumptions about a patient’s sexual orientation or to assume they are heterosexual. It is important to facilitate disclosure but also to respect non-disclosure
• A GP can make it easier for patients to disclose or talk about their sexual orientation by:
  • assuring the patient that consultations are confidential
  • adopting a non-judgemental attitude
  • using open questions such as ‘Do you have a partner?’
  • using gender-neutral, inclusive terminology
• Where a patient chooses to disclose their sexual orientation as LGB it is important that this is acknowledged and the terms they use are clarified.

Health Screening

Cervical Smear

• Lesbian and female bisexual patients are less likely to have had a cervical smear than women in general
• GPs and GP employed nurses should:
  • offer all women aged 25–64 a cervical smear regardless of their sexual orientation
  • offer women information about safer sex practices to reduce risk of acquiring human papilloma virus (HPV) regardless of their sexual orientation
  • ask inclusive questions when history taking around the smear test, e.g. ‘Are you sexually active at present?’ and if yes, ‘Do you have a regular partner?’ making sure not to assume heterosexuality.

Breast Cancer

• Lesbian and bisexual women aged 50–79 years are more likely to develop breast cancer than women in general—despite having similar rates of breast screening to the general population in that age group
• GPs and GP employed nurses should educate all eligible women about breast screening and breast awareness, regardless of their sexual orientation.

Substance Misuse

• The LGB and T population use all types of illegal drugs more than the general population. The reasons for higher substance misuse appear to be multifactorial
• The disparity between levels of substance misuse in the LGB and T population and the general population are highest in the 15–24 year old age group. LGB and T people are also less likely to access substance misuse services, often for fear of discrimination
• GPs and GP employed nurses should be aware:
  • of the higher rate of substance misuse in the LGB and T population
  • that LGB and T people may find it more difficult to seek help and access services.

Alcohol

• GPs and GP employed nurses should be aware:
  • of the higher rate of alcohol use in the LGB and T population and screen as felt appropriate.

Mental Health

• GPs should:
  • be aware of the increased risk of depression, self-harm, and suicidal ideation in LGB and T patients and screen patients for mental health risk factors if appropriate
  • recognise that conversion therapy is ineffective, inappropriate, and potentially damaging.

Sexual Health

• GPs providing sexual health services to LGB patients should:
  • only practice STI screening and management within their own level of competency and training. If GPs feel out of their depth—refer or sign post to Genito-Urinary Medicine (GUM) services
  • promote ‘the safer sex message’ to patients of all sexual orientations
  • be able to take an appropriate and confidential sexual history to assess risk of STIs in patients of all sexual orientations
  • be mindful that women who have sex with other women (WSW) or men who have sex with other men (MSM) may not always identify as L, G, or B
  • offer STI testing on the basis of risk rather than sexual orientation
  • be aware that if the patient is symptomatic they need to be offered a genital examination or referred to GUM
  • check if the patient needs assistance in accessing an appointment with GUM services and act as an advocate if appropriate
  • make themselves aware of their local level 3 GUM service and community based services, which can offer some STI testing—such as Brook clinic (male <25,female <20), The Rainbow Project (male only), outreach testing in gay venues, and walk-in MSM clinics in GUM
• When taking a sexual history you should consider the following guidance:
  1. ask to see the patient alone as this will reduce embarrassment and enhance disclosure
  2. obtain consent and warn about the nature of the questions, e.g. ‘I need to ask you some personal questions to help me advise you on the correct STI tests for you, would that be ok?’
  3. normalise the process, e.g. ‘We ask these questions to everyone with similar symptoms/difficulties’
  4. be non-judgemental and emphasise confidentiality
  5. try not to make assumptions about sexual practice or risk of STIs before you ask the questions
  6. avoid the terminology of LGB unless the patient identifies as such
  7. the language used should be professional but can be individualised for the patient or health practitioner
• STI screening should not necessarily be the first thing the clinician offers when a patient ‘comes out’. In order to understand the risks a patient might be taking it is important to take a more holistic view of their health. Engaging in high sexual risk behaviour may be an indication of other underlying problems, such as deteriorating mental health, social exclusion, or substance misuse.

Men Who Have Sex With Men (MSM)

• All MSM should be offered a three series course of hepatitis A and B vaccinations free on the NHS. It is important that GPs and GP employed nurses differentiate between these vaccinations schedules and travel vaccinations
• GPs should be aware that MSM patients:
  • should ideally be managed at a level 3 GUM service (consultant led)
  • could be offered opportunistic HIV testing in primary care
  • having unprotected sex with casual or new partners should have an HIV/hepatitis B and C/syphilis/STI screen at least annually, or every 3 months if changing partners regularly
  • may require triple site (urine, pharyngeal, and anal) testing for chlamydia and gonorrhoea based on sexual practice
  • should be offered a free accelerated course of hepatitis A and B vaccination and booster based on immunity.

Post-exposure Prophylaxis (PEP)

• As a GP or GP employed nurse you should:
  • be able to assess the patient’s risk of HIV exposure in the preceding 72 hours or contact GUM for advice
  • refer at-risk patients to GUM urgently for same day assessment if you believe PEP should be discussed
  • refer the patient to A&E for PEP if it is out of hours for GUM.

Lesbian and Bisexual Women and Sexual Health

• Lesbian and female bisexual patients often report they do not feel at risk of STIs, are too scared to get tested, or have been told by a healthcare worker that they do not need tested. Not all WSW will identify as L, G, or B. Patients that identify as L or B may be having or have had sex with a man in the past. Conversely, women who identify as heterosexual may be having sex or have had sex with a woman
• LB women have both oral and penetrative sex and can share fluids through hands, mouth, and sex toys. Although bacterial vaginosis (BV) can occur without sexual contact it is commonly sexually transmitted between LB women. Thrush can also be transmitted by sexual contact in LB women
• All STIs can be transferred between women. LB patients can get pelvic inflammatory disease (PID) most commonly from chlamydia infection. Given the risks of untreated PID, suspected PID should be treated.

Fertility Issues

• LB women may present requesting referral to fertility clinics. The NHS can help with donor insemination or in vitro fertilisation but this is very limited. To be eligible, the patient will need to be trying to get pregnant without medical help for at least two years and it must be proven that the patient has a medical condition that makes conception difficult
• Many LB women choose self-insemination to conceive. This raises issues of safety and the health of the sperm donor
• GPs and GP employed nurses should:
  • consider screening and treating female partners of women with BV
  • offer women information about safer sex practices to reduce risk of acquiring STIs regardless of their sexual orientation.

Care of Trans Patients in Primary Care

Terminology

• Transgender/trans—an umbrella term for people whose gender identity and/or gender expression differs from the sex assigned to them at birth. This term can include many gender identities such as: transsexual, transgender, androgynous, gender-queer, gender variant, or differently gendered people. Trans people may or may not decide to alter their bodies hormonally and/or surgically
• Gender Identity Disorder (GID)/Gender Dysphoria—A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex.

Key Considerations

• Be understanding. A negative reaction can do serious harm
• Get names and pronouns correct (ask discreetly if necessary)
• Be aware of the importance of medical confidentiality
• Refer to the appropriate gender service:
  • child and adolescent
  • adult
• Be cognisant that co-existing health issues may not be linked to gender issues
• Support the treatment set out by gender service
• Consider signposting to sources of support within the community and voluntary sectors, detail available through www.transgenderni.com.

What is Gender Dysphoria?

• Gender and sexual orientation are different
• It is not unusual for gender variance to present during early childhood or puberty.

Your Role as the GP

• An understanding and supportive GP is essential to the long-term health of Trans people, both in terms of transition and general wellbeing. It is important to remember that as a GP you may be the first person they tell about their gender dissonance
• Adults: It is important that for adults a referral to the Regional Gender Service is made with a view towards in-depth assessment and treatment
• Children and young people: For the child and adolescent population this referral would be to their local Child and Adolescent Mental Health Team who can access the Regional Adolescent Gender Team. Parents/carers may also need additional support from primary care
• Names and pronouns should match the gender presentation; if unsure it is good practice to discreetly ask
• It is important for patients that their GP remains actively involved in their care before, during and post transition
• It is important to recognise that transition may or may not include hormonal or surgical intervention.

Trans-specific Assessment and Care

• Over the course of their lifetimes, Trans patients are at much higher risk of negative mental health, self- harm and suicide than the general population
• Trans patients should be offered appropriate health screening (and other health services).