LGBTQ+ is an umbrella term that stands for lesbian, gay, bisexual, transgender and queer (Montz, 2021). It represents a variety of sexual orientations and gender identities that are not heterosexual or cisgender (a person whose gender identity matches with the gender they were assigned at birth) (Montz, 2021). Increased acceptance of people from the LGBTQ+ community is visible in the development of more inclusive UK laws (Marriage (Same-Sex Couples) Act 2013; Gender Recognition Act 2004; Equality Act 2010). The public has also reported increased acceptance of LGBTQ+ people (Nolsoe, 2021). Despite these developments, individuals that are LGBTQ+ still face inequalities in the healthcare sector. A UK survey showed that 108 000 people who identified as LGBTQ+ felt that their health needs were not being met by the healthcare system (Government Equalities Office, 2018). Research has shown that people who are LGBTQ+ are more likely to have negative experiences when accessing healthcare than non-LGBTQ+ people (Elliot et al, 2015). They often report that healthcare professionals (HCPs) do not have sufficient knowledge and experience to be able to meet their healthcare needs (McNeill et al, 2023) and that they have to educate them on health issues related to gender-identity, such as hormones (Willis et al, 2020).
Patients who are LGBTQ+ also tend not to disclose their sexual orientation as HCPs, typically, do not ask (Ching et al, 2021; McNeill et al, 2021), and because they sometimes experience clear homophobia and microaggressions (Fish and Williamson, 2018). This is a problem, as people who are LGBTQ+ are more likely to experience physical and mental health conditions (Elliot et al, 2015), such as later cancer diagnoses and higher rates of mental health issues (McDermott et al, 2021).
Limited research has explored HCPs’ experiences in providing care to patients from the LGBTQ+ community (McDermott et al, 2021). Existing data show that even though there are still instances of overt homophobia and transphobia, HCPs typically have positive attitudes toward LGBTQ+ patients. However, research suggests that they have limited knowledge about LGBTQ+ issues and the distinct needs of these patients (Berner et al, 2020; Ussher et al, 2022; Bailey et al, 2022). A review of the UK evidence further supported this. It showed that HCPs are uninformed about LGBTQ+ identities and terminology, particularly when it comes to transgender and non-binary individuals (McDermott et al, 2021). Medical students also report lacking confidence in LGBTQ+ language (Parameshwaran et al, 2017).
Past research has typically explored the experience of HCPs using surveys, which do not facilitate the gathering of in-depth narratives of participant experiences. It is important to explore in depth the views of a variety of HCPs, as people who are LGBTQ+ report issues in primary (Cant and Taket, 2006) and secondary care (Floyd et al, 2020). Also, different HCPs may face different barriers with their LGBTQ+ patients. For example, geriatricians treat older patients who have distinct needs which can impact on disclosure. Therefore, this study aims to explore HCPs’ experiences of supporting patients from the LGBTQ+ community.
The research objectives were to explore:
Method
Design and sample
This study adopted a qualitative case-study design, as this was ideal to facilitate the gathering of detailed and rich narratives. The inclusion criteria were:
Participants were recruited using the research team's professional network. Ethical approval was obtained from the University of Nottingham MSc Health Psychology Ethics Panel (Reference: MEDS4008-22-14).
Procedure
Initial contact was made via email by the first author (CP). If participants were willing to take part, an invite to the interview was sent. Participants were then asked to complete a demographic and consent form and email it back to CP before the interview. CP developed a topic guide for the interviews based on the literature (Box 1). The topic guide was used flexibly to allow follow-up questions and the exploration of emerging relevant topics. Interviews were conducted remotely via Microsoft Teams and audio recorded.
Data analysis
Audio files were transcribed verbatim, anonymised and analysed by CP using deductive thematic analysis (Braun and Clarke, 2012). The research questions were used as initial themes to guide analysis. Any new themes identified in the transcript were annotated and integrated into a tentative codebook. The codebook was discussed with the second author (CDL) until a consensus was reached on a final version, which was used to code all transcripts (Table 1).
| Theme | Sub-theme | Definition | Quotes |
|---|---|---|---|
| 1. Experiences of supporting patients who are LGBTQ+ | HCPs experiences with patients who are LGBTQ+ | ||
| Positive experiences | Positive experiences with patients who are LGBTQ+ and examples | ‘I suppose we were very sensitive around something that was probably very um embarrassing for him’ | |
| Negative experiences | Negative experiences with patients who are LGBTQ+ and examples | ‘A transfeminine patient who was admitted with cellulitis … they cut their leg shaving and this person was placed in a male bay in a ward … they were the subject of quite a lot of behind the curtain sniggering and derision’ | |
| 2. Facilitators and barriers | Facilitators and barriers to effective communication with patients who are LGBTQ+ identified by HCPs | ‘Just have to assume nothing and ask’ and be ‘open about asking people how they want to be addressed’ |
|
| 3. Confidence in practice | HCPs’ confidence in their ability to communicate with and treat patients who are LGBTQ+ | ‘There aren't many questions and queries that… would um worry me about asking, I feel like I would be quite open with people’ | |
| 4. Ideas for future practice | HCPs’ ideas about how the NHS and private sector could improve clinical practice in the future | ‘It's quite clear that unless its um unless it's done at a systematic level that it's impossible to embed’ |
Results
Eight HCPs were included (Table 2). The majority of participants were men (n=5; 62.5%). Most participants were consultant geriatricians (n=2; 25%). Seven participants were White British. Interviews lasted 33–55 minutes (mean=38 minutes).
| Participant ID | Gender | Age range | Ethnicity | Profession | Number of years practicing |
|---|---|---|---|---|---|
| P1 | Male | 55–64 | White British | Consultant geriatrician | 30+ |
| P2 | Male | 25–34 | White Irish | Hospital physician (geriatric) | 6–10 |
| P3 | Male | 65+ | White British | Psychiatrist | 30+ |
| P4 | Female | 55–64 | White British | General practitioner | 21–29 |
| P5 | Female | 35–44 | White British | Occupational therapist | 21–29 |
| P6 | Male | 45–54 | Mixed | Consultant geriatrician | 21–29 |
| P7 | Female | 35–44 | White British | Physiotherapist | 16–20 |
| P8 | Male | 55–64 | White British | Hospital consultant (medical) | 30+ |
Theme 1: experiences of supporting patients that are LGBTQ+
The majority of participants recounted a positive experience they had with a patient who identified as LGBTQ+. Patient disclosure about their sexual orientation was generally linked to enhanced rapport (and positive outcomes). P6 reported that when a patient had come out to him, he had been able to refer him to a local befriender scheme. This had enhanced the patient's social inclusion and emotional wellbeing. Providing effective support and care as a result of disclosure was also discussed by P4, who described an instance where a transgender male patient was offered individualised care by a GP whom they had come out to.
Participants also identified negative experiences with patients that are LGBTQ+. P5 and P4 reported that HCPs often made assumptions about the sexuality of patients who are LGBTQ+s, ‘particularly older people’. This led to patients losing their confidence in their HCPs.
Some participants had witnessed instances where the HCPs had been overtly homo- or transphobic with patients. P6 reported:
‘a transgender patient was admitted with cellulitis … they cut their leg shaving and this person was placed in a male bay in a ward … they were the subject of quite a lot of behind the curtain sniggering and derision.’
Similarly, P2 reported hearing about an older man coming out to a HCP, and being met with the response ‘oh, we don't need to hear about that’.
Theme 2: facilitators and barriers
HCPs generally reported that being open and not making assumptions, but rather asking patients about their background, were key facilitators to effective communication. While P1 felt that openness in communication was a facilitator, he felt that disclosure had to be initiated by the patient that is LGBTQ+:
‘Disclosure probably has to be offered by the LGBT person because I'm not going to tend to ask about it unless I think it is relevant in some way.’
P6 observed that open discussion about orientation and relationships were more problematic with older patients. P2 explained how this created an intersection of different layers of stigma against older patients:
‘They're marginalised twice. They're marginalised because they're older and they're marginalised because they're LGBT.’
He continued that there was a need to be ‘extra mindful’ with older patients who are LGBTQ+, who might be mistrusting of the healthcare system. Some described the value of kitemarking inclusivity through, for example, displaying the rainbow flag, in opening up communication. P2 described using ‘rainbow tape’ in the past on their ‘stethoscope as a visual cue that specifically [they were] LGBTQ+ friendly’. HCPs also identified potential barriers to effective communication. Participants felt that HCPs had limited understanding of LGBTQ+ issues. P6 explained that ‘staff are well meaning, but not skilled, and tend to then just avoid it rather than trying to talk to people about gender identity, sexual orientation, all those kind of things’. This suggests that HCPs typically wanted to communicate effectively, but lacked knowledge of the appropriate language and terminology.
Theme 3: Confidence in practice
Overall, HCPs felt confident in interacting with patients who are LGBTQ+ because they had a lot of experience talking to patients in general. P4 felt, as a result of their experience as an HCP, that ‘there aren't many questions and queries that … would um worry me about asking, I feel like I would be quite open with people’.
Dealing with patients that are transgender, P3 reported, presented added challenges:
‘There may or may not be difficulties in deciding what kind of accommodation to offer … a transgender man or a transgender woman or you know … people's experience dealing with non-binary people calling them “they”.’
He continued that members of the workforce were not ready to effectively support patients who are transgender.
Theme 4: Ideas for future practice
Participants were asked about whether they thought the NHS and private sector needed to improve clinical practice with individuals who are LGBTQ+ and how this might be achieved. Many participants felt that equality, diversity and inclusion (EDI) training needed to be improved. P3 recognised that ‘[LGBTQ+] is a big part of the EDI agenda generally … but I suspect it requires more attention’. P5 continued that EDI training should be patient-group-specific:
‘I think it would be no good to send everybody to the same training because different people in different settings with different ages ranges of … patients or service users have different … needs.’
Improving undergraduate medical training could also be beneficial. P6 felt that activities such as ‘role play scenarios’ and ‘simulation work’ could be helpful to ‘get people used to and comfortable with terminology’. P2 also expressed that while improving medical school teaching would be helpful, there should also be an effort to change the system by having information collected on patients who are LGBTQ+ on forms. Collecting patient data systematically also ensured monitoring of improvements, because in order to be able to measure change, P2 continued, ‘you need to know who the patients are’.
Other participants expanded on issues around equality and inclusion by advocating for improved healthcare for all vulnerable groups. P1 recognised the issue of intersectionality, whereby one person might be part of many vulnerable groups. P4 agreed with this view, and advocated for strategies to help multiple vulnerable groups, using a ‘multi-pronged approach’.
Discussion
The LGBTQ+ community still faces health inequalities, but little research has gathered in-depth narratives of HCPs in providing care to patients who are LGBTQ+. This study aimed to explore the experiences of HCPs in communicating with and treating patients who are LGBTQ+ and how communication with patients who are LGBTQ+ could be improved for HCPs such as GPs and practice nurses.
Participants reported several examples where LGBTQ+ patients were provided with effective, personalised care due to the HCPs being aware of the patient's identity. This fits with the findings that disclosure of identity to an HCP can lead to better health outcomes (Ruben and Fullerton, 2018). The positive experiences described by the participants involved acknowledging a patient's identity, taking special care of sensitive topics, and providing them with extra resources. Patients who are LGBTQ+ have unique needs, such as reduced service access, which could lead to poorer health outcomes. It is important that nurses, GPs and other HCPs can identify their patients that are LGBTQ+ and consider their distinct needs (Berner et al, 2020). It is also important to recognise that the LGBTQ+ community is very diverse and that different patient groups within the community will have distinct needs. This will require professionals with different specialisations to be able to appreciate the characteristics and needs of the population they support and address them effectively. For example, a geriatrician should appreciate the unique historical experience of stigma of older LGBTQ+ patients (Bailey et al, 2022), and how this might have an impact on disclosure (and therefore effective treatment).
The HCPs also described instances in which they had witnessed stigmatising behaviour that has also been reported in previous studies by patients who identified as LGBTQ+ (Fish and Williamson, 2018; Whyman and Di Lorito, 2022). Negative experiences have implications for patients who are LGBTQ+, as it leads them to delay or avoid access to healthcare services (Stonewall, 2018; Guest and Weinstein, 2020). Some participants reported that they would not directly ask a patient, especially an older patient, about their identity. This is consistent with research by Parameshwaran et al (2017), who found that only 50% of their student sample had witnessed a doctor ‘very frequently’ ask about sexual orientation and 2% had ‘very frequently’ or ‘always’ witnessed a doctor ask a patient about their gender identity. Research has shown that people will often not disclose or hide their identity if the HCP does not ask (Ching et al, 2021; McNeill et al, 2023). This could further lead to patient needs being unmet and poor health outcomes.
HCPs in this study reported feeling comfortable with patients who are LGBTQ+. However, they also reported lacking knowledge about their issues and making assumptions about their identities. Improving medical and nursing student education would be essential to address this. Also, updating EDI training to include information about LGBTQ+ terminology and communication is vital. However, training cannot be generic, as this ignores the needs of different patient groups. For example, older patients may be more hesitant to use services because of stigmatisation (McCann and Brown, 2019). Thus, training should be developed with consideration of the specific needs of different cohorts that the HCP works with. As well as consideration of the role of the HCP, for example, nurses often have the most interaction with patients and are vital in the provision of personal care which can be more stressful for patients who are LGBTQ+. Nurses need to be able to understand the patients’ important relationships to be able to identify that person's role in the patient's recovery process (Fish and Evans, 2016)
However, there also need to be institutional changes, such as systematically including sexual orientation and gender identity questions on intake forms, which should use inclusive language. The use of visual cues to show that services are accepting and welcoming of LGBTQ+ communities is also paramount. For example, the NHS rainbow flag badge was introduced to show patients that the individual they were speaking to is safe to open up to (Huckridge et al, 2021). Working with LGBTQ+ third sector organisations would enhance service understanding of the needs of LGBTQ+ communities and the kind of changes that should be implemented to meet them.
This study is characterised by certain strengths and limitations. One strength is that it is exploring an under-researched topic area. Therefore, it is contributing novel insight. In addition, the data came from a diverse group of professionals including GPs, physiotherapists and psychiatrists. Therefore, it contributes a variety of experiences from different professional backgrounds. This is important as different patient groups have distinct needs. For example, older patients who are LGBTQ+ have historical experiences of stigma that can make them mistrusting of healthcare services. The main limitation of this study is the small sample, which makes the findings not generalisable. The small sample is not representative as it does not include every type of HCP. Therefore, the findings cannot be generalised. Future research should aim to be more representative by including professions that were not in the current study.
Conclusion
Future research should expand on this study by interviewing other non-clinical patient-facing staff such as receptionists. To further expand on the study findings, further research should be conducted to understand more widely what kind of initiatives/strategies related to undergraduate teaching and EDI training should be implemented to better prepare the workforce of HCPs to effectively communicate and support patients who are LGBTQ+.