People identifying as lesbian, gay, bisexual and transgender (LGBT) are a sexual minority and suffer significant health inequalities compared to the heterosexual majority.¹ An estimated 1.7% to 9.9% of the adult population identify as LGBT but the validity of these estimates is questioned.¹ The issue of sexual orientation identification is complex. Just because a person has sexual experiences with or has an attraction to a person of the same sex doesn’t mean they will identify as gay or bisexual. Furthermore, many people will decline to answer when surveyed about sexual orientation.²

The Irish census does not ask people if they are gay or lesbian. Data on cohabiting couples show increasing numbers of self-declared same-sex couples over the past decade. The 2016 census found there were just over 6,000 same-sex couples living together, a 50% increase from the 2011 census.³

Attitudes towards LGBT people in Ireland are now regarded as among the most progressive globally. Same-sex sexual activity is legal and sexual and gender orientation is protected under anti-discrimination law. Ireland also forbids incitement to hatred based on sexual orientation. Recent transformative changes, in particular the legalisation of same-sex marriage in 2015, has emphasised the liberalisation of Irish society in this regard.

Since 2015, transgender people can self-declare their gender for the purpose of updating passports and driving licenses, obtaining new birth certificates and getting married. Irish law permits same-sex couples to adopt and a single gay person or one partner of a same-sex couple may apply to foster children. Lesbian couples have access to IVF and assisted insemination treatment and such couples who have had donor-assisted children in an Irish fertility clinic can register as their parents. 

Parents may choose the labels ‘mother’ and ‘father’ or instead the term ‘parents’, meaning the non-biological mother can legally register as a co-parent. In 2017, the Irish Blood Transfusion Service (IBTS) reduced the lifetime ban on blood donation for males who have ever had anal or oral sex with another male down to 12 months.

Health disparities

It is widely accepted that physical and mental health disparities exist between heterosexual and LGBT people. The LGBT community suffers higher rates of anxiety, depression, self-harm and suicide, as well as drug (including nicotine) and alcohol dependency.^4,5,6 There are also higher rates of diabetes, ischaemic heart disease, COPD, certain malignancies and STIs.⁶

Differences between sexual minority groups also exist, with bisexual people experiencing greater levels of health inequality.⁴ The majority of healthcare providers accept that minority stress is a key concept that explains these inequalities.^7,8 The term ‘minority stress’ describes the health consequences of stigmatisation, social exclusion, discrimination and harassment of minority groups.

The concept of minority stress is based on the understanding that alienation from social structures, norms and institutions can contribute to an accumulation of internal and external stressors, which impacts negatively on a person’s ability to cope.^7,8 High-risk health behaviour and inability to access healthcare are features of minority groups.

Sexual orientation disclosure

Disclosure of sexual orientation in a healthcare setting is linked to minority stress and may be a contributor to these health differences. LGBT people are often reluctant to disclose sexual orientation, which can delay or prevent them from accessing timely and appropriate healthcare.²

It is not known how many LGBT people in Ireland are ‘out’ to their GPs. In the UK, it is estimated that only half of LGBT people have disclosed their sexual orientation in primary care.⁹ Disclosure rates are even lower among bisexual and transgender people.⁹

The following facilitators to disclosure of sexual orientation have been reported:²

• Using inclusive language 
• Open and welcoming body language
• Being directly asked
• Patient registration forms adapted to depict a broad spectrum of sexual orientations (concern regarding the inclusiveness of the options provided)
• Long-standing relationship with healthcare provider
• Healthcare provider also a member of the LGBT community
• Healthcare professional being perceived as accepting of the LGBT community, or of their patient being LGBT
• More likely to disclose at sexual health clinics
• Visual clues at the healthcare setting (LGBT-friendly and human rights campaign leaflets, stickers and posters)
• Patients having higher levels of self-esteem, having a partner and/or higher levels of social support from friends.

The following barriers to disclosure of sexual orientation have been reported:²

• Closed-off or unfriendly body language 
• Use of heteronormative language (assumptions of heterosexuality), in particular in the context of providing contraception and sexual health services 
• Fear of discrimination, including receiving poor or unequal healthcare
• Fear that disclosure will have a negative impact on career or benefits 
• Criminalisation 
• Fear of negative personal reaction from a healthcare provider
• Feelings of embarrassment or humiliation
• Concern regarding breaches in confidentiality
• Less likely to disclose in military-or religious-affiliated health settings 
• Religious symbols or icons displayed in the healthcare setting
• LGBT people from ethnic minorities who identify as bisexual, do not have a college education and have a low income are less likely to disclose their sexual orientation to a healthcare professional.

Recommendations

Improving the health and wellness of LGBT people in Ireland is an important public health goal¹⁰ and Irish GPs  can play a critical role in improving the health inequalities identified among sexual minorities. Creating a welcoming location (surgery waiting area) and a safe space (consultation) for LGBT people to disclose their orientation are the starting points for increasing their engagement in medical care.²

Environment

At an institutional level, the design of healthcare settings should take into account the needs of LGBT patients. Some changes are easily implemented and inexpensive, such as displaying signs or symbols that convey an accepting atmosphere (rainbow symbol or the Human Rights Campaign logo). A key intervention is the production of patient information leaflets that display acceptance of the LGBT community and consider the differing needs of LGBT individuals compared with heterosexual individuals, providing LGBT-specific information when necessary.

Individual level

GPs should also consider asking questions about each patient’s sexual orientation in their daily practice, using open and accepting language. Individual healthcare professionals should be aware of the differing physical and psychological needs of LGBT individuals and remain open-minded regarding the sexual orientation of their patients. 

Healthcare professionals are encouraged to reflect on their use of language and keep an eye out for heteronormative phrases and assumptions, as well as those that may be inhibiting their patients’ ability to disclose. The most common example of this is referring to a patient’s partner as ‘he’ or ‘she’, rather than asking whether they are male or female. Consider using alternative terms such as the following:

• Aromantic: A person who experiences little or no romantic attraction to others and/or has a lack of interest in romantic relationships/behaviour
• Asexual: A person who experiences little or no sexual attraction and/or a lack of interest in sexual behaviour. They may or may not experience emotional, physical or romantic attraction. Asexuality differs from celibacy in that it is a sexual orientation, not a choice
• Bisexual (bi): A person who experiences attraction, sexual or otherwise, to members of more than one gender
• Cisgender: A person whose gender identity corresponds to the sex they were assigned at birth
• Gay: Used in some cultural settings to represent men who are attracted to men in a romantic, erotic and/or emotional sense. Not all men who engage in same-gender sexual behaviour identify as gay, and as such, this label should be used with caution
• Gender expression/role: Outward manifestation of one’s gender identity, usually expressed through masculine-, feminine- or gender-variant behaviours. Trans people typically seek to make their gender expression match their gender identity, rather than their birth-assigned sex
• Gender identity: A person’s internal psychological identification as man/woman, boy/girl or neither. For transgender people, their birth-assigned sex and internal sense of gender identity do not correspond
• Genderfluid: A person who does not identify or express their gender within the gender binary
• Genderqueer: Genderqueer people may identify as neither men nor women and see themselves as outside of the gender binary or may feel restricted by gender labels
• Heterosexism: Prejudice against people who display non-heterosexual behaviours or identities, combined with the majority power to impose such prejudice
• Intersex: An umbrella term describing people born with any of 30 variations in sex characteristics including chromosomes, gonads, sex hormones or genitals
• Lesbian: Women who experience sexual, romantic, physical, and/or spiritual attraction to other women
• Non-binary or enby: A person whose gender identity does not fall within the binary genders of man or woman
• Pansexual: A person who experiences attraction, sexual or otherwise, to members of all gender identities
• Queer: A word with many definitions that means different things to different people. It can refer to attraction to people of many genders, it can describe someone who doesn’t conform to cultural norms around gender and/or sexuality, or it can be used as a general term referring to all non-heterosexual people. Some within the community, however, may feel the word has been used hatefully against them for too long and are reluctant to embrace it
• Questioning: An individual who is unsure of and/or exploring their gender identity or sexual orientation
• Transgender (trans): A term for people whose gender identity/expression differs from the sex assigned to them at birth. This term can include transsexual, transgender, androgynous, genderqueer, gender-variant or differently gendered people. Trans people may or may not decide to alter their bodies hormonally and/or surgically
• Transsexual: A desire to live as a member of the opposite sex, usually accompanied by a discomfort with one’s anatomic sex and a wish to have surgery/hormonal treatment to make one’s body congruent with one’s preferred sex
• Transition: A process through which a permanent change of gender role is undertaken and the individual starts to live as the gender with which they identify. This includes social, physical and legal changes such as coming out, changing one’s appearance, name, pronoun and sex designation on legal documents, and medical intervention.

Training and medical education

Incorporating more LGBT-specific knowledge and communication skills into undergraduate medical education is essential in aiding sexual orientation disclosure. This problem stems from the beginning of medical education, with little or no time in undergraduate and postgraduate medical courses dedicated to an LGBT-dedicated curriculum.^11,12

Incorporating more LGBT-specific knowledge and communication skills into undergraduate medical education is essential to ensuring future healthcare professionals are armed with the tools necessary to empower their patients to disclose sexual orientation, as well as provide them with appropriate care and advice. The responsibility for medical education does not just sit within the undergraduate realm; there should also be an increased presence of LGBT-specific issues and appropriate communication tools in postgraduate curricula.

Further study into issues surrounding disclosure from a healthcare professional perspective could provide a fuller understanding of the complexities surrounding sexual orientation disclosure in healthcare. Ideally, robust population-level studies that include an accurate portrayal of the diversity encompassed within the LGBT community are needed. Our current understanding of sexual orientation may be restrictive and limiting and may not display the full spectrum of orientations. It may focus only on sexual identity rather than attraction or behaviours. An alternative means of monitoring those who describe themselves as ‘other’ would allow a far richer and much-needed analysis of the population. 

Below is a list of useful LGBT-related publications, websites and support organisations:

• The Psychological Society of Ireland: Guidelines for good practice with lesbian, gay, bisexual clients – which can be accessed on www.psychologicalsociety.ie by searching for the title or scrolling down to the bottom of the homepage and clicking ‘PSI Guidelines, Policies & Papers’
• Health Service Executive: LGBT Health – HSE – which can be found on www.hse.ie by searching for ‘LGBT health’
• •We Belong: Parent support groups  – which can be found on www.belongto.org/parents/parent-support-groups/
• Health Service Executive: Gay men’s health services – which can be found on www.hse.ie by searching for ‘Gay men’s health’
• •Gay Switchboard Ireland – https://gcn.ie/listing/gay-switchboard-ireland/
• Gay Community News – https://gcn.ie/
• RCGP NI: Guidelines for the care of LGB patients in primary care and Trans-patient Guidelines for GPs both of which cab be found on the webpage www.rcgp.org.uk/policy/rcgp-policy-areas/lgbt.aspx
• ICGP and GLEN: Lesbian, Gay and Bisexual Patients: The Issues for General Practice – which is available on www.ilga-europe.org by searching for the title and scrolling down to the relevant document in the search results

References

1. Hudson-Sharp N, Metcalf H. Inequality among lesbian, gay bisexual and transgender groups in the UK: a review of evidence. 2016
2. Brooks H, Llewellyn CD, Nadarzynski T, Pelloso FC, De Souza Guilherme F, Pollard A et al. Sexual orientation disclosure in health care: A systematic review. Br J Gen Pract. 2018 Mar 1;68(668):e187-96
3. Families - CSO - Central Statistics Office [Internet]. [cited 2019 Nov 19]. Available from: https://www.cso.ie/en/releasesandpublications/ep/p-cp4hf/cp4hf/fmls/
4. Elliott MN, Kanouse DE, Burkhart Q, Abel GA, Lyratzopoulos G, Beckett MK et al. Sexual Minorities in England Have Poorer Health and Worse Health Care Experiences: A National Survey. J Gen Intern Med [Internet]. 2015 Jan 5 [cited 2019 Nov 19];30(1):9-16. Available from: http://link.springer.com/10.1007/s11606-014-2905-y
5. Semlyen J, King M, Varney J, Hagger-Johnson G. Sexual orientation and symptoms of common mental disorder or low wellbeing: combined meta-analysis of 12 UK population health surveys. BMC Psychiatry [Internet]. 2016 Dec 24 [cited 2019 Nov 19];16(1):67. Available from: http://www.biomedcentral.com/1471-244X/16/67
6. Sandfort TGM, Bakker F, Schellevis FG, Vanwesenbeeck I. Sexual orientation and mental and physical health status: Findings from a Dutch population survey. Am J Public Health. 2006 Jun;96(6):1119-25
7. Lick DJ, Durso LE, Johnson KL. Minority Stress and Physical Health Among Sexual Minorities. Perspect Psychol Sci. 2013 Sep;8(5):521-48
8. Meyer IH. Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Vol. 129, Psychological Bulletin. 2003. p. 674-97
9. Mitchell M, Howarth C, Kotecha M, Creegan C. Sexual orientation research review 2008
10. Health Service Executive. LGBT Health: Towards Meeting the Health Care Needs of Lesbian, Gay, Bisexual and Transgender People [Internet]. 2009 [cited 2019 Nov 19]. Available from: https://www.hse.ie/eng/services/publications/topics/sexual/lgbt-health.pdf
11. Obedin-Maliver J, Goldsmith ES, Stewart L, White W, Tran E, Brenman S et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. J Am Med Assoc. 2011 Sep 7;306(9):971-7
12. Parameshwaran V, Cockbain BC, Hillyard M, Price JR. Is the Lack of Specific Lesbian, Gay, Bisexual, Transgender and Queer/Questioning (LGBTQ) Health Care Education in Medical School a Cause for Concern? Evidence From a Survey of Knowledge and Practice Among UK Medical Students. J Homosex. 2017 Feb 23;64(3):367-81