Should all patients be asked about their sexual orientation?

I agree with the author that great health benefits can be achieved by knowing a patient’s sexuality when offered voluntarily - however patients rarely have the opportunity to volunteer their sexuality in a consultation, and for LGB people this can leave them feeling uncomfortable and misunderstood by their physician. By asking all patients about their sexual orientation, we offer an opportunity for LGB patients to share an important aspect of their identity with us that they may not have felt able to previously.

Much of the author’s objection to sexual orientation monitoring seems to rest on the idea that the general population will be offended or uncomfortable with being asked about their sexuality. However, a GP practice in Greater Manchester that implemented SOM in 2012 found that 95% of patients were happy to have their sexual orientation recorded on their medical file, and 98% understood the importance of collecting this information (1). ONS research has shown asking about sexuality is broadly as acceptable as asking other monitoring questions, such as ethnicity (2).

Therefore, I think we must consider that a major barrier to sexual orientation monitoring is not that it makes the patient uncomfortable, but rather that the doctor feels too uncomfortable or embarrassed to ask about sexuality. This is a rather doctor-centred approach to the consultation, and as already acknowledged in order to achieve good medical practice we should be focusing on the needs of the patient. In the spirit of patient-centred communication, in the minority of patients that may express discomfort, explaining to them the importance of sexual orientation monitoring should assuage their concerns – the LGBT+ Foundation’s Good Practice Guide has some excellent examples (1).

I think it is also important to recognise that there are many opportunities to collect information about sexual orientation, and that a healthcare worker needn’t open every consultation by asking about sexuality. The information can be collected upon registration, in a self-complete questionnaire with other demographic data, or at a relevant point in the consultation. Taking the patients mentioned above as examples, it would be extremely relevant to ask the 17-year-old about their sexual orientation as part of a sexual history, given the prevalence of sexually transmitted infections in their age group. For the 70-year-old, assuming the information hadn’t already been collected over the preceding 35 years, it would be particularly pertinent as part of a social history given older LGBT adults more likely to live alone, and may struggle nominating someone to make end of life decisions (3).

The author very rightly asks if there is any good evidence that patients with different sexualities are treated differently – the Stonewall report ‘Unhealthy Attitudes’ (4) found that 25% of NHS staff have heard colleagues using homophobic language in the last 5 years, whilst 10% of staff think LGB people can be 'cured' using conversion therapy; so we know that there is prejudice within our health service. But how do we measure whether LGBT patients are treated differently if we don’t know who they are? One of the most pressing reasons to implement sexual orientation monitoring is that we desperately need this data in order to assess the extent of homophobia and discrimination within the NHS.

In order to achieve the best care for our patients, it is important to have a holistic view of them as a person, and that includes sexuality which is an important aspect of a person’s identity. It affects someone’s social circumstances, their risk of mental health problems, their use of alcohol, drugs and cigarettes, their sexual health, and access to healthcare - and that could just be the tip of the iceberg. Only by collecting data on sexual orientation will we be able to explore this further.

References
1. LGBT Foundation. Good Practice Guide to Monitoring Sexual Orientation [Internet]. LGBT Foundation; 2017. Available from: https://s3-eu-west-1.amazonaws.com/lgbt-media/Files/b577e0cd-041a-4b10-8...

2. Office for National Statistics. Sexual identity: update on research and testing [Internet]. 2018. Available from: https://www.slideshare.net/secret/HwBiX0XCGQSAGN

3. Almack K, Yip A, Seymour J, Sargeant A, Patterson A, Makita M. The Last Outing: exploring end of life experiences and care needs in the lives of older LGBT people [Internet]. The University of Nottingham; 2014. Available from: https://s3.amazonaws.com/academia.edu.documents/45159937/The_Last_Outing...

4. Stonewall. Unhealthy Attitudes: The treatment of LGBT people within health and social care services [Internet]. Stonewall; 2015. Available from: http://www.stonewall.org.uk/sites/default/files/unhealthy_attitudes.pdf