Primary Colours “Exploring and understanding the barriers for

1. Primary Colours “Exploring and understanding the barriers for Lesbian, Gay, Bisexual and Transgender people in accessing primary healthcare, and how they impact on their health.” Mark Hedley 2012

2. Area of residence

3. Sexual orientation

4. Choosing a GP Practice Participants chose the GP practice for a number of different reasons: • Nearest practice to where they live (49%) • Practice used by their family (31%) • Recommended by friends or family (18%)

5. Sexuality, sexual orientation or gender identity known to GP

6. “I had made a decision not to be out to my GP because I wasn’t really comfortable with the subject of being gay myself. I was in my first relationship at the time and it was impacting on the relationship, I had a reason to be at the GP for something else and I thought well I’ll see how the session goes, and if I feel okay about it then I will maybe mention to the GP that I was thinking I might need to speak to a counsellor or something, we were in the session and it happened to be about an infected scratch I had in a difficult to reach place. She put a dressing on and said that the dressing would need to be changed in a few day’s, and that she could give me a replacement dressing if there was someone at home who can help with it, it was great because she’d asked a question that wasn’t related to the gender of my partner. I was just about to open my mouth and ask about counseling sessions to help me with my sexuality and she said, right obviously if you get your boyfriend to change the dressing for you there’ll be no need for a nurses appointment, straight away I clammed up and didn’t ask what I wanted to ask which left her confused because I’d already said there’s a couple of things I might want to talk to you about. I left quite abruptly so I don’t know what she thought was going on and just tried to carry on as usual at home. The issue kept coming back into my mind, so in the end, because this was an issue that was really related to my sexual orientation and the ongoing problems I was having overwhelmed me again and in a fit of pique, rang the doctors and made an appointment to speak to her again. I really had to psyche myself up to say what it was and I think in the end was so agitated that I said the first thing that came into my head in one big go, I think at that point she thought I was accusing her being gay, I told her that she had made an assumption about my partner being male during my last appointment and it meant that I couldn’t say to you what the issue was, but the fact is that I’m gay and I’m struggling with it and I wanted counseling and she said, oh, oh, right, well then, that’s fine. The sessions got set up and that was fine, but the whole issue could have been resolved months and months earlier if she just hadn’t made that assumption and said it out loud. At the time I wasn’t in a place where I could contradict her and say, well actually it’s a female partner I have at home, because she’d made that assumption there was no way that I could then say well actually I’m gay and I’m struggling.” (Lesbian 45 years)

7. LGBT Information displayed in GP Practice

8. “It doesn’t have a lot of room for lots of information around the walls or magazine racks or anything like that but what there is tends to be very family orientated” (Lesbian 43 years) “It just gives you the impression that everyone who goes there is heterosexual and there’s no room for anyone else. It’s not particularly inclusive; show me something, like a mission statement or a policy about equal opportunities or equality and diversity or something like that” (Gay male 45 years) “There was a poster of two men holding hands, but it was like they were just posters that were there, it was a generic GP practice and there were neighbours down the road that went there and it was just very normal” (Gay male 45 years) “The thing that attracted me to the surgery was that they had the rainbow flag up in the window” (Trans Female 43 years)

9. “In their basic information you said your name, your address, your gender, and then it said are you single, married, widowed or divorced and I said look, why do you need this information, I’ve never been married, I’m a gay man, so I’ve never been divorced and I haven’t been legally widowed but I had a partner who died. If you’re asking if there’s anyone special in my life then yes I’m living with my partner, that’s why I’m here and not in Middlesbrough any more, but you’re not asking that, so why are you collating this information? It would be helpful to have a co-habiting because there’s a whole number of people who would at least be able to be included in that who are currently excluded by this question, and so consequently it makes me feel like I’m less valued by this practice and as a person, in terms of the paperwork it was just rubbish, really, really rubbish” (Gay male 45 years)

10. Equality Act 2010 • In October 2010 the Equality Act came into force • The Act is now a key part of the legal framework that underpins the way the NHS provides its services and supports its staff. The Equality Act outlaws discrimination against the following protected characteristics:

11. Equality Act 2010 • Age • Disability • Gender reassignment • Marriage & civil partnerships • Pregnancy and maternity (Department of Health 2010) • Race • Religion or belief • Sex • Sexual orientation

12. Discrimination experienced at GP practice

13. “They assume heterosexuality, which makes things awkward” (Lesbian 46-50 years) “No protective equipment available (the right condoms being made available), being told none were available” (Gay male 31-35 years) “My doctor had ‘Homosexual’ in big letters on my file on the computer at the surgery. Historically the word Homosexual has been used in medical terms to describe an illness; I am a Gay man not ill” (Gay male 36-40 years) “I was refused cervical screening despite family history as I was classed as a low risk as was not sexually active with a man” (Lesbian 31-35 years) “GP will not change title” (Trans female 26-30 years)

14. Links between sexuality/sexual orientation and health • Of those participants who suggested there was a link 22 went on to highlight what in their opinion the health issues were, with one encapsulating what a number of LGBT people feel by suggesting: ‘Everyone’s health has a connection with their sexuality. Your sexuality is part of your identity and this is closely linked to your well-being’ (gay male 51-55 years)

15. Links between sexuality/sexual orientation and health The most common health issues highlighted were: Drug & alcohol Cervical smears • HIV • Mental health • Sexual health “In the past I’ve suffered from depression, caused by feelings of isolation due to my sexuality” (Gay male 36-40 years) “There are particular risks and issues that gay men have, particularly around sexual health” (Gay male 26-30 years) “I have much better mental health since coming out” (Lesbian 51-55 years)

16. Links between sexuality/sexual orientation and health “I had a cervical smear, which showed pre cancerous changes that I had to have removed. This was the first smear I had in 20 years because there was little awareness in our community about the importance of smears. I went to have the cells removed and the surgeon asked me how long it was since I had sex with a man. My female partner was in the room at the time and I was sat in the surgical chair waiting to have a colposcopy. He nearly fell off his stool when I told him it was over 20 years. What scared me was that potentially I had been at risk for this length of time. I also didn’t think this question should have been asked of any woman regardless of her sexual orientation whilst in such a vulnerable position”. (Lesbian 41-45 years)

17. Sexuality/sexual orientation discussed during consultations

18. Do you think your GP Practice could be improved to support LGBT patients?

19. Ways to improve service provision

20. “Make clear the practice is LGBT friendly when first joining” (Lesbian 41-45 years) “Positive same sex information & images” (Gay male 36-40 years) “Sexuality should be discussed initially in general/first consultation with all patients” (Gay female 21-25 years) “More visible images of LGBT people, posters, flyers, leaflets offering services & information” (Lesbian over 65 years) “I often get my partner referred to as you wife” (Gay male 41-45 years) “GPs should have a greater understanding of the support that LGBT people need” (Lesbian 51-55 years) “Just an LGB poster on the wall can make a huge difference” (Gay male 36-40 years)

21. “I want to emphasis that I don’t want loads and loads of special treatment. I just want to feel like I can access the services on the same basis that everybody else can, but in order to do that I need somebody somewhere to acknowledge that on some level lesbian, gay, bisexual and transgender people matter and they matter even when they are feeling vulnerable or it’s something to do with their health. At the moment the only time I see anything that identifies LGBT people in my surgery is when I go into the toilets and look at myself in the mirror” (Lesbian 43 years)

23. Recommendations A number of simple and cost effective ways to improve LGBT peoples access to primary health care were identified, which in turn would have a positive impact on breaking the barriers discussed during this research project have been identified. • 87% of participants suggested simply promoting LGBT services throughout the practice in the reception and waiting areas as well as consultation rooms i.e. posters & leaflets. • Another suggestion was the inclusion of information promoting the service as being LGBT friendly in a practice statement. This would send out a message to all patients that the service supports equality and diversity

24. Recommendations Staff training and awareness of services was also highlighted • This could be delivered in house or by including sessions during ‘Time Out’ training days, if sessions were offered during the above GP practice training days it is important they are accessed by both clinical and reception staff • Alternatively there is a one-day LGBT Awareness training course available, which is part of the Newcastle Sexual Health Training Programme. This course is delivered by staff from Mesmac North East and SHINE and is free of charge • There are also established courses run by Northumbria University for nursing and medical professionals that include modules on sexual health

25. Recommendations There are a number of excellent web-sites both locally and nationally where promotional literature can be accessed, these include: • Mesmac North East – www.mesmacnortheast.com • LesBi Sexy and Healthy – www.lesbisexyandhealthy.co.uk • Stonewall – www.stonewall.org.uk • Terrence Higgins Trust (THT) – www.tht.org.uk • Trans Support - NE and Northern Cumbria Gender Dysphoria Service (NHS) - ady.davis@northumberlandcaretrust.nhs.uk

26. References • Ash, M. and Mackereth, C. (2010) Mental and Emotional Health Needs Assessment of the LGBT (Lesbian, Gay, Bisexual and Transgender) populations of NHS South of Tyne and Wear: Gateshead, South Tyneside and Sunderland. Available at http://www.equality-ne.co.uk (Accessed 15th January 2012). • Department of Health, (2007) Mental health issues within lesbian, gay and bisexual (LGB) communities. Department of Health: London. • Department of Health. (2010) Equality Act. Department of Health: London. • Gotbaum, B. et al (2008) Improving Lesbian, Gay, Bisexual and Transgender Access to Healthcare at New York City Health and Hospitals Corporation Facilities – Executive Summary. Public Advocate for the City of New York. • Health Protection Agency. (2008) Sexually Transmitted Infections and Men who have Sex with Men in the UK: 2008 Report. Available at http://www.hpa.org.uk (Accessed: 15th January 2012). • Keogh, P. Et al (2004) Doctoring Gay men: Exploring the contribution of General Practice. Sigma Research, London. • Smith, G., Bartlett, A. and King, M. (2004) ‘Treatments of homosexuality in Britain since the 1950s – an oral history: the experience of patients’. Available at http://www.bmj.com (Accessed: 15th January 2012).

27. Mark HedleySexual Health Promotion Specialist mark.hedley@nuth.nhs.uk