In October 2017, the National Health Service (NHS) England began compelling doctors and nurses to ask patients age 16 and older about their sexual orientation. The policy, which is intended to reduce discrimination, has supporters and critics. Meanwhile, in the United States, there are worries that new measures from U.S. President Donald Trump could target gay and transgender patients. A government department is being set up to support health care workers who use religious objections as the basis for refusing treatment.
The NHS England guidelines and FAQs recommend that health professionals such as family doctors and nurses ask about a person's sexual orientation at any opportunity for face-to-face contact with the patient, unless of course the information has already been obtained. Under the guidance, which was developed in by Manchester's LGBT Foundation in collaboration with NHS England and others, health professionals should ask patients: "Which of the following options best describes how you think of yourself?" The options include heterosexual or straight, gay or lesbian, bisexual, other sexual orientation, not sure, not stated and not known.
Health professionals are advised to use discretion when asking. For instance, it is obviously more relevant to ask about sexuality at a sexual health clinic than one that treats minor skin problems. As well, the guidance states that it is not appropriate to ask someone's sexual orientation aloud in a busy reception area. The policy states pointedly that patients are not compelled to disclose their sexuality. Should they choose not to, the patient's response is recorded as "not stated."
NHS England said the policy was enacted because lesbian, gay and bisexual patients have been disproportionately affected by health inequalities such as poor mental health and other issues. A study found that rates of smoking, alcohol and drug use are higher among gay and bisexual men as compared to the general population. That puts them at disproportionate risk of cancer, heart disease, stroke and other common conditions. LGBT patients are also at higher risk of self-harm and suicide.
The people who run the U.K.'s health care system argue that collecting and analyzing data on sexual orientation is the first step in improving access to medical service for LGBT patients. Not only that, paying mind to the needs of LGBT patients has been the law of land since the Equality Act was passed by the British Parliament in 2010.
Some British doctors are concerned about the policy. Dr. Peter Swinyard, the head of the U.K.-based Family Doctor Association, told the BBC it was "potentially intrusive and offensive" for GPs to monitor the sexuality of their patients. He said that sexuality is not relevant in a 10-minute visit with the family doctor. He added that sexuality doesn't affect health care or health outcomes.
And, in a debate published last week in the British Medical Journal, GP Dr. Michael Dixon wrote that for most patients, sexuality is a private matter. Dixon conceded that many patients would probably answer a question about sexuality without hesitation. Still, he predicted that some would feel the need to lie, eroding trust within the doctor-patient relationship, and possibly affecting their health. Dixon added that patients who refuse to declare their sexuality might be labelled as difficult patients. Concerns have also been raised that declaring one's sexuality might increase discrimination. Dixon wrote that the best way to avoid discrimination of LGBT patients is to not know their sexuality.
Unfortunately, there is evidence that some doctors discriminate against LGBT patients is justified. A 2015 survey of health professionals published in the American Journal of Public Health found that heterosexual providers favour heterosexual people over lesbian and gay people. Other surveys have found that female to male patients have reported verbal harassment, physical assault, or denial of equal treatment in a doctor's office or hospital.
Some of the bias comes from lack of education. A study of the curriculum at U.S. medical school found that medical students received an average of just five hours of LGBT-specific training.
Last week, the Trump administration announced that new rules were being developed to shield healthcare workers who do not want to provide services to transgender patients. The rule creates a new division in the Health and Human Services (HHS) Civil Rights Office to assist healthcare workers who say they were forced to provide services contradicting their religious or moral beliefs. Activists say the move will increase discrimination against LGBT people and might even compromise lifesaving care.
I can see the logic in asking everyone about their sexuality. However, if handled poorly, it might lead to embarrassment and discomfort. I think it might be better for a health professional to begin by affirming that every patient has a right to be treated with respect and dignity, and that one's sexuality should never be a barrier to that. I would add that everyone is entitled to privacy. I would encourage the patient to talk about anything they feel important to disclose, including their sexuality, especially if they believe it has a bearing on their health.
We need to be mindful that some patients may be struggling to come to terms with their sexuality, and that forced disclosure might make them feel anxious. If doctors are able to open up that line of conversation with their patients in a respectful way, it might lead to better mental health outcomes for patients.
However, I would stress that they should not feel compelled to reveal anything they're uncomfortable talking about. Whatever the approach, I think it's critical that health professionals try and imagine what it's like to be the patient being asked questions that are intrusive and highly personal.