Don't ask,sometimes tell. A survey of men who have sex with men sexual orientation disclosure in general practice

Abstract

Despite advances in lesbian, gay, bisexual and transgender equality in recent years, some men who have sex with men remain at increased risk of ill-health. Positive interventions in primary care include psychological support and strategies for risk reduction. It is important that men who have sex with men can disclose sexual orientation in primary care. To quantify disclosure of sexual orientation by men who have sex with men attending general practice and identify barriers to disclosure we surveyed a group of Scottish men. A questionnaire was distributed by voluntary organisations and the National Health Service in the West of Scotland, to rural and urban populations. Two hundred and four gave evaluable responses, with all ages represented. A total of 199 (98%) were registered with a General Practitioner and 167 (83%) attended in the previous year. A total of 81 (40%) stated staff were aware of their sexual orientation. A total of 93/121 (75%) men who have sex with men whose GP was unaware stated this was because they had never been asked. A total of 36/81(44%) men who have sex with men rated support from practices since disclosure as ‘excellent’ and qualitative responses were positive. It is reassuring that almost all respondents were registered with GPs and attending primary care services. However, only 40% had disclosed sexual orientation. This was not because of fear of negative impact on care but because men who have sex with men felt it was irrelevant to their attendance. GPs appear to be reluctant to raise the issue of sexual orientation without prompting.

Keywords

Homosexuality bisexuality men who have sex with men MSM primary health care general practice sexuality disclosure

Introduction

Over the last decade, significant progress has been made in some countries to promote equality and protect the rights of lesbian, gay, bisexual and transgender (LGBT) people.¹ After many years of campaigning, same-sex marriage was legalised in England, Wales and Scotland, in 2013.² It is reported that men who have sex with men (MSM) may experience greater levels of discrimination, stigma and prejudice that may be associated with sexual identity.³ There are higher rates of mental ill health than in the general population, particularly in younger MSM⁴ and greater use of tobacco, alcohol and recreational drugs.^3,5 MSM may consult with primary care services more frequently than the general population and GPs are well placed to offer appropriate interventions and support.

The third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)⁶ showed that 8% of men reported lifetime sexual contact with another man, with little variability between age groups. This percentage was similar to surveys in previous decades (Natsal 1 and 2). Fifty-one per cent of men who reported sex with another man in the previous five years had tested for HIV.⁶ Behavioural interventions can help reduce sexually transmitted infection and HIV acquisition in MSM^7,8 but to be offered, these require initial disclosure of sexual orientation. Although many specialist sexual health services and third sector organisations specifically support the sexual, mental, physical and social health needs of MSM, not all individuals will be able or willing to access these directly.⁸ Natsal-3 also showed an increased acceptance of same-sex partnerships amongst the general population compared with previous decades.⁶

An American survey study from 2014⁹ reported that patients attending primary care services found it acceptable to be asked about sexual orientation on registration and 75% of respondents agreed that it was important for the practice to be aware of sexual orientation.⁹ Previous studies of health service utilisation by gay and bisexual men in the UK have shown that most men are registered with a GP practice and this population is relatively common users of GP services with 78–81% having attended within the previous year.^10,11 The 2004 Sigma Research study on the contribution of general practice to support the health of MSM¹⁰ drew on qualitative data from 13,244 respondents who participated in the Gay Men’s Sex Survey 2003.¹² A total of 27.5% of the men registered with a GP stated that surgery staff knew their sexual orientation and a third of all gay and bisexual men in this study, who were registered with a GP, said the staff at that GP surgery did not know they had sex with men and they would be unhappy if they did know. The three key explanations why men said they would be unhappy that GP surgery staff knew that they had sex with men were given as being: reasons about themselves (shy, embarrassed, uncomfortable, not fully ‘out’, married, with children, small town, rural area); reasons about the specific practice (irrelevant, not their business, confidentiality concerns, a specific reason characteristic of a staff member such as gender, religion, age or ethnicity) and reasons about potential consequences of disclosure (insurance, medical records, stigma and discrimination).

The objective of our study was to quantify the rate of disclosure of sexual orientation by MSM to primary care practitioners in our region in Scotland, which includes both rural and urban areas, in the era of greater LGBT equality and to identify any barriers to disclosure. Quantifying disclosure rates and tackling such barriers has the potential to improve the provision of sexual health services to MSM, especially those who do not wish to or are unable to access specialist services.

National strategic context for our study setting was provided by the NHS Quality Improvement Scotland (QIS) sexual health services standards published in 2008.¹³ Key themes developed (including from public consultation and the participation of an advocacy group whose membership included representation from Stonewall and other LGBT organisations) included access to services, co-ordination of approach, equity of service provision and quality of care delivery in general practice as well as in specialist and generic sexual health services. The QIS standards comprised 12 sets of standards, one of which supported offering MSM at risk of sexually transmitted hepatitis B, immunisation in community settings such as primary care, thereby providing MSM a choice of setting to access vaccination.¹³ However, it was recognised that this was only possible if MSM disclosed sexual orientation in primary care. Following formal peer review visits to assess progress made delivering the service standards across Scottish NHS Boards, a national overview report identified a continuing need for primary care to engage in the provision of generic sexual health services and support expanded vaccination services for MSM.¹⁴

Methods

The West of Scotland sexual health services Managed Clinical Network (MCN) was established in 2009 to support service improvement.¹⁵ As part of its work programme to ensure equitable clinically effective services, an MSM Steering Group was established which designed a questionnaire survey with input from sexual health specialists, primary care colleagues and third sector organisations/individuals for distribution to MSM. The questionnaires included both closed questions and structured questions with provided responses and the option of free text (see Appendix 1 in the supplementary material online). The free text responses were collated alongside the structured answers and were reproduced verbatim for the analysis. After piloting, including client and staff feedback, in a specialist sexual health clinic for MSM, the survey was made available in an online format, using ‘Surveymonkey’¹⁶ and also in paper form. The paper forms were returned in sealed envelopes to the MCN office where the responses were manually entered on ‘Surveymonkey’.

The questionnaire was distributed for self-completion both in electronic and paper form to self-identified MSM by the following methods:

MSM attending specialist sexual health services in the five NHS Boards in the West of Scotland MCN;¹⁵

The Steve Retson Project¹⁷ (a specialist NHS sexual health service for gay and bisexual men in Glasgow);

Online (via email distribution) and paper distribution by third sector organisations: Terrence Higgins Trust Scotland,¹⁸ Gay Men’s Health¹⁹ and LGBT Youth;²⁰

Opportunistic completion at third sector group meetings and an MSM focus group.

Results

A total of 204 evaluable responses were received during the study period from October 2011 to March 2012, with each respondent answering some or all of the questions. The age breakdown was broadly even as seen in Table 1. Not all questions were answered by all of the respondents and the denominator states how many respondents answered each question.

Table 1.

Age of respondents.

16–19	11% (22/204)
20–24	19% (39/204)
25–29	13% (26/204)
30–34	13% (26/204)
35–44	20% (40/204)
45–54	18% (37/204)
55 and over	7% (14/204)

Table 2 summarises sexual orientation as self-described by the respondents.

Table 2.

Self-defined sexual orientation.

Gay	83.3% (169/203)
Bisexual	15% (31/203)
Heterosexual	1% (2/203)
Other	0.5% (1/203)

One man did not respond to this question.

The sample was drawn from respondents living in a mixture of urban, semi-rural and rural locations. The largest proportion of men identified themselves as resident within the NHS Greater Glasgow and Clyde health board area (40%, 83/203) with 24% (50/203) from NHS Ayrshire and Arran, 7.4% (15/203) from NHS Dumfries and Galloway, 2.9% (6/203) from NHS Forth Valley and 16.7% (34/203) from NHS Lanarkshire. A total of 7% (15/203) were from other parts of Scotland and one did not answer.

A total of 98% (200/204) stated they were currently registered with a GP, with 83% (168/204) having attended for any reason in previous year.

See Figure 1 for results of whether their GP was aware of sexual orientation. Two respondents did not answer this question. This was a closed question with no free text options for which the responses were ‘Yes’, ‘No’ or ‘Not sure’. The latter two responses were classified together as GP being unaware.

Figure 1.

Are medical/nursing staff at your GP practice aware of your sexual orientation?

Of those who answered that the GP knew their sexual orientation, MSM were asked how the GP had become aware and they could tick more than one option. The answers are summarised in Table 3. These responses suggest that only 1.9% (4/204) of all participants had been directly asked by their GP about sexual orientation.

Table 3.

Eight-one men were asked, ‘How did the GP become aware of your sexuality?’

‘They asked me directly during a consultation’	5% (4)
‘I told my GP during a consultation’	75% (61)
‘I assume that they know’	12% (10)
‘My partner is also registered with the practice’	7% (6)
‘It’s probably in my notes’	21% (17)

Of those MSM who answered ‘No’ or ‘Not sure’ (60%, 123/204), the respondents were given tick box options to explore why. Respondents could tick all that applied plus include any additional comments. The responses are shown in Table 4.

Table 4.

One hundred and fourteen respondents answered the question ‘If your GP is not aware of your sexual orientation, why is that?’

‘I’ve never been asked’	81% (93)
‘It’s never been relevant’	73% (83)
‘I’ve never been to see them about anything to do with sex’	57% (65)
‘I’d be concerned about confidentiality’	14% (16)
‘I’m worried about their attitude to me if I disclose’	15% (17)
‘I’m confident about my sexual orientation and do not need support from my GP’	35% (40)
‘I never attend or don’t have a GP’	2% (2)
‘I do not want it noted in my medical record’	20% (22)
‘I don’t want to be pigeon holed by my sexual orientation’	18% (20)
‘I’m worried about non-medical staff in the practice knowing my sexual orientation’	13% (15)
‘I think the quality of my medical care would be compromised as all my problems would be related to my sex life’	9% (10)
‘I’m worried that people within my local community would find out’	4% (5)
Other comments
‘Mental health stress around sexuality was part of this, I would prefer they didn’t know’
‘I attend a sexual health clinic elsewhere for any sexual health checks and so far haven’t had the need to discuss anything with my GP’
‘Never needed to be disclosed’

The participants were then asked if they felt they could approach their primary care clinician with certain personal issues and the responses can be found in Table 5.

Table 5.

‘Would you feel comfortable raising any of the following issues with your GP or practice nurse?’

Concern	Yes	No	Not Relevant
Stress, depression or mental health problems	84% (162)	9% (18)	6% (12)
Relationship concerns	37% (70)	40% (74)	23% (44)
Domestic abuse	45% (84)	23% (43)	31% (58)
Alcohol or drug issues	74% (139)	10% (18)	16% (30)
Sexually transmitted infections or HIV	69% (130)	24% (46)	7% (13)
Sexual problems including erectile dysfunction	71% (135)	19% (35)	10% (19)
Parenting issues including plans or desire to have children	36% (67)	17% (32)	46% (85)
Violent crime including rape, sexual or physical assault	53% (99)	22% (40)	25% (47)
Bullying or harassment	40% (74)	31% (58)	29% (53)
Other gay, bisexual or transgender issues, including coming out	42% (78)	37% (69)	22% (41)

Of those who had disclosed sexual orientation to their GP, only 4% (5/80) said it had negatively affected the relationship with their doctor and 70.5% (55/78) rated the service received as ‘very good’ or ‘excellent’. Qualitative responses were also generally positive and most respondents felt the support received and experiences with their GP had not changed since disclosure of sexual orientation. This view was also stated by those who had not disclosed same-sex partners (‘No’ and ‘Not sure’) with 80.9% (93/115) saying they did not expect it would make any difference to the service provided and only 13% (15/115) saying they felt it would deteriorate. This suggests that men would disclose sexual activity with same-sex partners if they thought it was relevant or it was directly raised by the GP.

There were several comments on how practices could be more inclusive, which we have grouped into themes.

Equality awareness

‘Perhaps they could display posters encouraging inclusiveness in their reception areas’

‘At least have one LGBT inclusive poster or “nod”. We’re not all singles mothers, people with kids or OAPs!’

‘Non-judgmental/professional attitude not affected by cultural/society conditioning’

Communication

‘Make it widely known that my sexual orientation could not be disclosed for employee medicals as I am not “out” to my GP in case it affects employment or life insurance’

‘Being supportive if the patient is seeking it but otherwise but acting a way that they would with a straight patient, with the exception of issues that are affected by sexuality’.

‘More communication from the individual to your GP and from the GP to the patient’

‘A person's sexual preference should not be marked on their file as this can make insurance etc. more expensive’.

‘When speaking to patients, using the term “partner” would be more useful, it is open ended and allows patients to disclose sexuality if they want to’.

‘More consistency in seeing the GP you are registered with i.e. if practice could allocate you a slot with your GP rather than a locum’

Staff training

‘More open information about the training that doctors have been on to deal with LGBT issues, and more information on what issues you can/should take to them’

‘Have a bit more training on dealing with issues that gay/bisexual men encounter that straight males may not encounter’

‘Maybe have a dedicated Nurse/Doctor that can deal with Gay issues’

Discussion

Summary

This study, in the era of greater LGBT equality and effective combination HIV therapy, details the relationship between sexual orientation disclosure (specifically MSM) and primary care services in geographical settings within Scotland. It also highlights MSM views on disclosing sexual orientation to primary care services and documents that GPs rarely ask men directly about same-sex partners.

Strengths and limitations

This study attempted to recruit men from a range of locations and settings other than just from specialist sexual health services. The respondents were approached via organisations and services targeted at MSM and therefore by definition the men who agreed to participate were willing to engage to some extent. Generally, men who were comfortable as self-identifying as MSM will have been accessed for this survey and therefore there will be under-representation of men who engage in sexual activity with other men but do not identify as gay or bisexual. In NHS-provided services, identification of potential respondents was primarily by medical staff and therefore MSM known to other members of the multidisciplinary team may have been missed.

Comparison with existing literature

Our study supports the findings of the previous Sigma research study,¹⁰ which found a high percentage of MSM are registered with GPs and have high rates of attendance (78.8% attended in the last year). Keogh et al. found only 27.5% had disclosed sexual orientation to their GPs but an older UK-based study found 56% of MSM had disclosed sexual orientation to their GP,¹⁰ which is in keeping with our findings. There are older studies which examine caregivers’ attitudes towards sexual health management in primary care²¹ and towards sexual history taking.²² Another study, which examined disclosure rates of sexuality of lesbian, gay and bisexual patients across healthcare providers in the United States,²³ found 60% of respondents disclosed their sexuality to the healthcare worker, which is higher than in our survey, although this was not specific to primary care. Most respondents regarded their sexual orientation as irrelevant to their healthcare. The more recent US study examined acceptability of asking about sexual disclosure with positive findings.⁹

Implications for practice

This survey revealed that the majority of participants in our setting were not only registered with a GP but had also engaged recently with primary care services. Whether sexual orientation had been disclosed or not, most men felt that disclosure would not have a negative impact on care, although there were a few exceptions evidenced by the comments concerning confidentiality and accessing insurance. The proportion of respondents who reported consulting with a GP in the last 12 months was higher than we anticipated for men of this age group. This may either suggest that MSM are either more willing to engage in medical care or that the respondents comprised individuals who were regularly unwell or at concerned about becoming feel unwell.

From this survey, not many GPs appeared to directly raise the issue of sexual orientation, as few respondents indicated having been specifically asked by the GP. Clinicians should recognise the importance of sexual orientation and how this might influence care delivery if known. In addition to our findings, the 2014 US study⁹ suggests that men attending primary care services increasingly find it acceptable to be asked about sexual orientation when registering in primary care for the first time. We would therefore challenge health care professionals to improve on our finding that fewer than one in 50 men were asked directly about same-sex partners.

The majority of respondents reported a positive view of their GP and their practices, but 41.6% of respondents indicated that sexual orientation was irrelevant. This suggests that many MSM do not appreciate that same-sex relationships might be relevant in terms of the medical care and support received from primary care. Therefore, future initiatives to highlight the importance of disclosure of sexual orientation in receiving the right healthcare and support should not simply address primary care practitioners but also MSM themselves.

The opportunity for men to express comments and suggestions revealed that MSM would like GP practices to be more relevant. MSM perceived that the main focus of primary care was disproportionately on other populations. Some common themes for suggested improvements emerged from the comments received including:

•A general equalities statement on display in the waiting area explaining that the practice does not discriminate on the grounds of race, gender or sexual orientation and that anything shared with practice staff will be confidential;

•More relevant posters, leaflets and other info for LGBT people including for local organisations or services which may be relevant;

•Enhanced staff training on equalities and sexual orientation and discussing this with patients;

•Dedicated clinic hours or a nominated doctor for MSM/LGBT patients;

•An effort to improve communication between the doctor and the patient.

To conclude, this study has shown that MSM may on occasion disclose sexual orientation to clinicians in general practice, but only if they feel it is directly relevant to the consultation (‘sometimes tell’). It is uncommon for GPs to specifically ask men about same-sex partners (‘don’t ask’). However, MSM who did disclose their sexual orientation in primary care generally reported positive support and some rated this as ‘excellent’.

Footnotes

Acknowledgements

With thanks to the respondents who participated in this study and the clinicians in the West of Scotland sexual health services Managed Clinical Network MSM Steering Group who distributed the questionnaire. We also wish to acknowledge the third sector organisations who were partners in the project: THT Scotland, LGBT Youth, Gay Men’s Health and Waverley Care.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This study was undertaken by the West of Scotland sexual health services Managed Clinical Network without additional funding. The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

The study proposal and questionnaire was submitted to the West of Scotland Ethics Committee, who confirmed that there was no need for full ethical approval.

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