Should all patients be asked about their sexual orientation?BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k52 (Published 17 January 2018) Cite this as: BMJ 2018;360:k52
- 1Department of primary care and public health, School of Public Health, Imperial College London, London UK
- 2Devon, UK
- Correspondence to: R Ma , M Dixon
After decades of campaigning by lesbian, gay, bisexual, and trans (LGBT) charities such as Stonewall and the LGBT Foundation, sexual orientation became one of the nine protected characteristics written into the Equality Act 2010.1 It would seem a logical and welcome step for NHS England to include sexual orientation monitoring (SOM) in health and social care systems.2 In practice all professionals would ask patients how they define their sexuality during every encounter. Patients can, of course, refuse to answer.
However, some doctors and patients have expressed concerns about this policy, citing reasons such as intrusion or invasion of privacy, fear of causing offence, doubts about relevance, data security, and that it is a tokenistic gesture that will not make a difference. While I understand these concerns, they result in inertia; and failure to act undermines hard fought rights of LGBT patients to better healthcare.
Flawed assumptions about need
We already fail the LGBT community by not recognising, or by making incorrect assumptions about, their needs. A Stonewall commissioned survey of nearly 7000 gay and bisexual men found that smoking, alcohol, and drug use were more prevalent in this group compared with men in general.3 More specific health needs include mental health: 6% of gay and bisexual men aged 16 to 24 have attempted to take their own life in the past year compared with less than 1% of men of the same age in general; 15% have reported self harm compared with 7% of other men.
Some people think SOM is relevant in sexual health related consultations only. This is a narrow view. Ethnicity is more than colour of your skin. Gender is more than your chromosomes. Similarly, SOM isn’t just about sex. History, culture, lifestyles, as well as struggles against discrimination, are some commonalities that unite non-heterosexual identities.
Even if SOM were just about sex, we are not even getting that right. Despite men who have sex with men being at higher risk, only a quarter and a third have been tested for sexually transmitted infections and HIV, respectively.3 A Stonewall commissioned survey of over 6000 lesbian and bisexual women reported that 15% of eligible women have not had a cervical smear compared with 7% of other women.4
Equal treatment is not fair treatment
Some think that treating everyone equally should be good enough. But equal treatment is not fair treatment. You would not offer vulnerable patients equal access to care like other patients—you make a special effort because of the special need. Neither can you say that you offer equitable care to LGBT patients without knowing who they are—unless you count them.
We must reflect on why we think asking about sexual orientation is “intrusive” and “insensitive”; and why some patients refuse to disclose such information. This is surprising given that a large probability sample survey of over 15 000 adults in Britain (the third National Sexual Attitudes and Lifestyles Survey) reports that 11% of women and 8% of men have had same sex sexual experience; and we have more liberal attitudes to same sex relationships than 20 years ago.5
We must create an environment where people can disclose information on their sexual orientation safely. According to a survey of more than 3000 health and social care staff, only 9% received training on needs of LGBT people; but half said that their training covered only sexual health; 16% admitted they would feel uncomfortable asking patients about their sexuality and, in contrast, they felt more comfortable asking about other protected characteristics, such as disability.6 Perhaps the health service has outdated sexual attitudes and we need to catch up.
I agree that we must make the public feel confident in how their data are used. We need to make our data secure and show that we are using them intelligently—from contextualising a person’s care and management, to service improvements.
Sexual orientation monitoring is necessary to make the health service for LGBT patients fairer. If we don’t count our LGBT patients, they don’t count.
Making doctors ask all their patients about their sexual orientation is political correctness gone mad. No one doubts that there can be great health benefits from knowing a patient’s sexuality, when offered voluntarily. There are also many occasions when, and patients for whom, it is quite appropriate for a doctor to ask. It is the “all patients” bit that is wrong.
Patients’ best interests
If I start asking my 17 or 70 year olds about their sexuality, the former will think that I am weird and the latter that I have gone bonkers after being their GP for 35 years. If I then apologise and say that I am only asking because of the Equality Act and because the Care Quality Commission will be checking on me, then they might rightly wonder whether I have their best interests in mind. Sexuality, for many people, is a private thing and not an appropriate descriptor of who they are.
A patient asked about their sexual orientation has three options. To tell the truth, which is easy for many and especially, I expect, for those who support this idea. Alternatively, a patient may feel that he or she has to lie, which is bad for them, for the doctor-patient relationship, and for later consultations, when the question might be more appropriately asked and more truthfully answered. The third and quite understandable option is that the patient tells the doctor to take a running jump, in which case we are to record, in Kafkaesque terms, “The patient declined to answer.” This implies that he or she has either got something to hide or is a difficult patient.
Apparently, this is all to stop discrimination under the Equality Act, but surely the best way to avoid discrimination is by not knowing people’s sexuality in the first place. Is there good evidence that people with different sexualities are treated differently, and, much more to the point, is there any good evidence that asking them will improve things? The powers that be, NHS England, say that it won’t affect patient treatment—prompting the question of why bother?
Robots practising medicine by numbers
This stupid idea symbolises the continuing erosion of medical autonomy beckoning an age when GPs become politically correct robots practising medicine by numbers. It is yet another example of overmanagement in general practice and will see yet another flood of clinicians escaping to the Antipodes or out of medicine altogether in order to elude Big Brother’s silly rules. The secretary of state for health recently warned that we are on the verge of losing the family doctor.7 Surely someone should be doing something about that rather than filling our time with more useless tasks?
In good medical practice, the patient’s own needs, wishes, choices, beliefs, culture, and perspective should come first—not the rules or diktats of any higher body. Ultimately it should be up to the judgment of each GP as to when it is appropriate or useful to ask such questions. The NHS needs to assert itself as a kind, compassionate, and intelligent service rather than a nosey parker grinding us all into cynical submission.
What about the patient? I asked my 97 year old mother what she would think if her GP asked her about her sexual orientation. “He wouldn’t,” she said confidently. “Yes, but suppose you were registering with a new doctor, and he or she asked about your sexuality?” “Well dear, I would find another doctor.”
Competing interests: We have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.