Exploring the individual experiences of LGBT+ patients with general practice staff: an interview-based study

Over the past few decades, society as a whole has become more aware and accepting of individuals identifying as LGBT+ (lesbian, gay, bisexual, transgender and other identities) (Payne, 2013; Flores, 2019). LGBT+ rights and awareness have been improved through legislative changes (Gender Recognition Act 2004; Marriage (Same Sex Couples) Act 2013), as well as advocacy efforts and portrayal in the media. Nonetheless, society in general remains widely heteronormative (assuming that heterosexuality – being sexually attracted solely to people of a different sex – is the preferred or normal mode of sexual orientation) and cisnormative (assuming that cisgender – gender identity that match the person's sex – is the norm (Logie et al, 2018)). This perpetuates a double standard making LGBT+ individuals exposed to the risk of discrimination, which can be blatant, such as bullying and hate crimes, or more subtle and implicit in areas including education (Ng et al, 2019), work (McFadden and Crowley-Henry, 2018) and social media (Abreu and Kenny, 2018). One setting where such experiences can also be harmful is healthcare. Research found that healthcare settings may display heteronormative and cisnormative values (Davy and Siriwardena, 2012; Mkhize and Maharaj, 2020) such as by recording only patients' biological sex and not gender identity (Dolan et al, 2020), potentially neglecting identities such as transgender identities.

The first health professionals that the general public visit for a range of medical matters are general practitioners (GPs) and other general practice staff. Research suggests that the attitudes and knowledge of staff working in general practice around LGBT+ individuals and their medical needs are very variable. For instance, LGBT+ patients have reported having to educate GPs on LGBT+ matters, or that GPs are uncomfortable discussing topics such as lesbians' sexual health (Hinchliff et al, 2005; Willis et al, 2020). Such incidents could be due to systematic pitfalls, such as lack of standardised training (Taylor et al, 2018), and/or to negative views of GP staff toward patients' LGBT+ identities. Anticipated or actual discrimination by GP staff could have a negative impact on LGBT+ patients' mental health. LGBT+ individuals have been found to be exposed to a higher risk of mental health issues than the general population (Russell and Fish, 2016; Yarns et al, 2016), making any discrimination by GPs and other primary care staff particularly threatening, as it could potentially discourage access to further healthcare and support.

While previous research has explored healthcare professionals' approaches to LGBT+ patients, these studies often focus on medical areas other than general practice staff, such as radiography (Bolderston and Ralph, 2016) and end-of-life care (Makita et al, 2020). Given that general practice is the first port of call for health-related consultations, more research is needed in this area. This study aimed to explore LGBT+ individuals' experiences of interacting with staff working in general practice, as well as thoughts of how their attitudes and behaviours to LGBT+ patients can improve.

The research questions were:

• What are LGBT+ individuals' experiences of interacting with staff in general practice?
• What are some positive and negative impacts of such interactions?
• What improvements do participants feel could be made in the interactions of general practice staff with LGBT+ patients?

Materials and methods

Design

This study employed a qualitative methodology. It complied with the consolidated criteria for reporting qualitative research (COREQ) (Tong et al, 2007).

Sample

Inclusion criteria:

• 18+ years old;
• Identifies as LGBT+;
• Has recent (ie no more than 1 year before recruitment) experience of visiting a general practice. Ideally, the staff were aware of the participant's LGBT+ identity, in order to gauge their responses to these identities.

Participants were recruited via social media between June and July 2021. Recruitment was facilitated by the York LGBT Forum. The York LGBT Forum was chosen due to an established collaboration with the research team. The first author (SW) designed a poster to be advertised by the organisation, and on relevant social media platforms (eg LinkedIn) to maximise recruitment. Individuals interested in participating contacted SW to receive more information about the study and, if interested and eligible, to schedule an interview. Ethical approval for the study was given by the Research Ethics Committee of the University of Nottingham.

Procedure

Due to COVID-19 restrictions, all participants were interviewed remotely through Microsoft Teams or over the phone, depending on their preferences. Interviews were audio-recorded using a password-protected phone, which did not upload to any file sharing software, such as the Cloud. At the start of each session, the participant was recorded verbally affirming their consent to take part in the study. Next, demographic information, including age, gender and sexuality, was collected from participants. A schedule (Box 1), informed through literature-based research, was developed to guide the interviews. This schedule was used flexibly to allow exploration of new topics emerging during the interviews.

Box 1.Interview ScheduleDemographic questions

• Age
• Gender and pronoun
• Sex assigned at birth, if relevant
• Ethnicity

‘This interview is aiming to explore any experiences you've had with GPs. This can be for appointments arranged regarding your LGBT+ identity, or for any other matters. You can ask for clarification on any questions if you don't understand, and if you feel uncomfortable answering any questions, please let me know and we can move onto another question.’

• 1. Can you describe any positive experiences you've had with GPs, specifically when you've felt understood and respected in your LGBT+ identity? What would say were the main features of these appointments that made them positive for you?
• 2. How do positive interactions like these impact you, such as relating to the matter that you attend the GP for, as well as personally?
• 3. Can you describe any negative experiences you've had with GPs, when you've thought that the way you were treated was related to the GP's views on your LGBT+ identity? Can you specify what features of these interactions made them negative for you?
• 4. How do negative interactions like that impact you, such as relating to the matter that you attend the GP for, as well as personally?
• 5. Have you ever visited the GP with a partner? If so, how were you treated as a couple?
• 6. When you've had negative experiences like this, have you ever addressed or confronted this at the time? For instance, have you said to the GP ‘That makes me uncomfortable; please don't say/do that?’
• 7. Have you sought support following negative experiences with GPs? Have you received support within the LGBT+ community or organisations, or from friends and family? If so, how did that go? What kind of response did you get from the GP?
• 8. If you've visited various GPs or different healthcare settings, have you noticed your experiences being different or similar? How does that difference make you feel?
• 9. How do positive experiences with the GP make you feel about returning to the GP if you need to?
• 10. How do negative experiences with the GP make you feel about returning to the GP if you need to? Would you feel reluctant to book a GP appointment in the future due to concerns that you would be treated negatively again?
• 11. In your opinion, how do you feel interactions between GPs and LGBT+ patients can improve?
• 12. Is there anything else you would like to discuss?

Data analysis

Interviews were transcribed verbatim by SW from the audio recordings. Transcripts were analysed using inductive thematic analysis (Braun and Clarke, 2006) to allow for evidence to emerge from the data. SW annotated transcripts to identify individual codes. Once all six transcripts were coded, SW created mind maps to identify common themes to which codes could be allocated. Potential themes were then reviewed, and sub-themes were identified through discussion with the second author (CDL). A codebook was then developed (Table 1), which summarises themes and sub-themes identified through the coding process.

Results

Six participants were included (Table 2): three gay men, two lesbians and one non-binary person, aged 21–77 years (mean=36 years, SD=20 years). Five participants were white; one was British African-Caribbean. Interviews lasted 17–33 minutes (mean=27 minutes). Three main themes were identified, with a number of sub-themes (Table 1).

Theme 1: Patient experiences

All participants had attended at least one appointment during which the general practice staff had been aware of their LGBT+ identity. Most participants had experienced variation in how the staff responded to their identity.

All participants had some positive experiences with general practice staff. P1 (non-binary, 37 years old) recalled a positive interaction during a telephone appointment with GP staff:

‘It was the first time they actually phoned up, called me (preferred name), and they used ‘they’ and ‘them’ pronouns.’

P1 continued ‘I was bouncing off the roof, I got quite excited’, showing how validating the acknowledgement of their identity was. Along the same lines was P6, a 77-year-old gay participant. Of the general practice where he has been registered for 19 years, P6 said:

‘They just treat you like a human being … it isn't about sexuality or anything like that. It is just “Yes, you've got a problem, we need to sort it”.’

P4, a 23-year-old gay man, also felt that equal treatment is a key feature of positive interactions with staff at GPs, recalling a recent appointment:

‘I was telling (the GP) how I feel like people are judging me. I thought that was triggering my anxiety. (The GP was) very supportive. I never felt, like, berated or negatively judged.’

Participants also reported some negative interactions with GP staff, including instances where their identities were misunderstood, stereotyped or ignored. P2, a 39-year-old gay man, explained that he was assumed to be HIV-positive when he presented to the GP with a virus:

‘I was very sick for a while … I had lost a lot of weight, so I was very thin and also pale. The GP saw on the clinical history that I was gay, and he just assumed I had HIV. That was very disappointing, to be honest.’

P2 also recalled an experience during which a GP appeared to stereotype same-sex intercourse as inherently risky:

‘The GP said something like ‘Well, you shouldn't be checking for HIV so often, if you have not engaged in these types of risky behaviours.’

P2 explained he viewed this comment as ‘prejudicial,’ as the GP appeared to make this statement based on personal beliefs ‘instead of using scientific data’ to appropriately discuss risk of sexually transmitted infections.

Additional negative experiences include GP staff being unaware of patients' identities, even if stated in patient notes. P5, a 21-year-old lesbian, stated:

‘I did put down ‘lesbian’, and since then, even though I've had a few appointments, they don't look at my notes.’

P5 stated this leads to her ‘coming out during the appointments over and over again,’ which she would ‘rather not do.’

Further comments relate to GP staff openly ignoring participants' identities. P1 (37 years old) recalled that when they initially tried to discuss their gender identity with a GP, ‘he just completely and utterly ignored me. I might as well have been talking to a brick wall.’

Overall, participants reported great variations in interactions with different GPs and other members of staff. Positive experiences included acknowledgement of an LGBT+ identity when appropriate while being treated inclusively. Negative experiences involved general practice staff being unaware or deliberately dismissive of participants' identities.

Theme 2: Outcomes of GP appointments

This theme outlines how interactions with GP staff affected patients' satisfaction, emotional wellbeing and future service access.

P5 (21 years old) experienced frustration at repeated recommendations to take the contraceptive pill to treat painful menstrual cramps. This was because, as a lesbian, P5 did not require the pill to prevent pregnancy, and she also felt it was not guaranteed to improve her menstrual cramps, meaning its benefits were limited. She stated:

‘Every single time it's been ‘Well, just go on birth control,’ and I'm like ‘Er, I don't really want to go on birth control. Have you got any other options for me?’ You know, bearing in mind I don't really have any other benefits to that.’

P5 continued that she is very dissatisfied by the fact that medical treatments are tailored to cis (cisgender) women, meaning that her needs are often neglected.

Interactions with GP staff also had negative emotional impacts for many participants. P1 stated that GP staff dismissing their gender identity ‘upset me because it's took me a long time to actually realise I didn't want to transition into male, but I definitely knew I wasn't female.’ Unfortunately, P1 continued that they still ‘expect’ that GPs and receptionists will use their incorrect name and pronouns in the future, concluding that they have had to ‘accept that it is like that at the GP and it's not going to change any time soon.’

P5 voiced her concerns regarding her and her girlfriend's plans to pursue fertility treatment in the future. Given her previous experiences of having her sexuality questioned by GPs, P5 worried how she and her partner would be treated as a lesbian couple in that situation. P5 explained that:

‘If me and my partner go down any pregnancy kind of thing (fertility treatment), that is already terrifying. Thinking about dealing with my GP makes it even scarier!’

The negative experiences reported by participants had an impact on their trust toward their GPs. P2 (gay man, 39 years old) stated that he found being stereotyped by his GP ‘scary’, explaining that the possibility of a GP's knowledge around LGBT+ topics being ‘compromised’ made him question about other aspects of their skills, such as their medical knowledge. P3 (lesbian, 21 years old) continued that, while she has not experienced direct homophobia from GPs, she would stop going if this occurred, saying ‘I think any practice that keeps a GP like that wouldn't be one that I'd want to stay at.’

These statements illustrate how negative interactions could discourage future access to care in times of need, which for some LGBT+ people is the only means of support. For instance, P3 and P4 stated they would not turn to family to discuss their own personal issues, and P5 (lesbian, 21 years old) stated ‘I do talk to my partner now, but before meeting her, I didn't talk to anyone about it, which isn't easy, when you need help.’

Theme 3: Improvements to GP staff attitudes and behaviours

This theme discusses participants' views of how interactions between general practice staff and LGBT+ patients can improve.

P2 acknowledged a need for training ‘around communication’ and asserted that some GP staff ‘probably need to be more tactful’ when discussing matters of sexuality with patients, such as HIV testing. P6 expanded on such views by asserting a need for training ‘for the practice as a whole,’ including receptionists and healthcare assistants, who P6 said are ‘key in all of this, because that's often the first point of contact.’ Therefore, there appears to be a consensus among participants for the need for improvement in GPs' communication and literacy around LGBT+ experiences.

As well as discussion around standardised improvements, some participants also emphasised the need to respect individual patients' preferences. These may include whether patients prefer to receive care from male or female staff. For example, P6 (77 years old) recalled that when his late partner was in hospital being treated for dementia, he was assumed to prefer a female carer. P6's partner was in fact more comfortable with male carers, a preference which was not explored. P6 linked this experience to general practice, stating that all healthcare professionals, including GPs, should consider and respect such preferences in order to facilitate patient comfort. P5 also discussed possible preferences of LGBT+ patients when interacting with general practice staff. She suggested that patients may prefer to visit a GP when they know there is a member/champion of the LGBT+ community, a person who holds specialist knowledge in LGBT+ matters. This could help patients feel more at ease and better understood during their interactions with general practice staff.

Overall, participants mostly felt that standardised training across NHS England for general practice staff could greatly improve their interactions with LGBT+ patients. However, participants also note that individual preferences should be explored and fulfilled where possible, to maintain a holistic, patient-centred approach to LGBT+ healthcare.

Discussion

Despite recent progress in equality and inclusivity in society, the continued prejudice toward members of the LGBT+ community in settings such as healthcare warrants further research into their experiences. The current study aimed to explore experiences of LGBT+ individuals' interactions with staff working in general practice.

Participants reported variation in the knowledge of staff working in general practice around LGBT+ identities, reflecting findings in other medical settings, such as nursing (Carabez et al, 2015) and mental healthcare (Rutherford et al, 2012). Variation in knowledge holds unique risks for LGBT+ patients, as patients may be apprehensive as to whether their own GPs will be knowledgeable and accepting of their identity, or whether they may experience discrimination.

Regarding positive experiences, in line with findings by Sharek et al (2015), being respected in their identities by general practice staff made participants feel that they received equitable treatment. Such experiences helped participants feel that their needs were met, and that GPs were not fazed by their identities. Given the panoply of benefits associated with accepting LGBT+ individuals across settings (Ryan et al, 2010; Greytak et al, 2013; Longarino, 2019), acceptance by general practice staff can be expected to greatly benefit many patient outcomes. Indeed, several participants stated that feeling comfortable with a GP contributed to them being forthcoming with information, which in turn benefitted treatment outcomes.

Meanwhile, participants recalled that GPs judging or questioning their identities caused feelings of fear, frustration and isolation, similar to findings from Luvuno et al (2019). Such negative experiences held various consequences for participants, impacting treatment outcomes, mental health and future service access. LGBT+ individuals are at a higher risk of severe mental health issues (Russell and Fish, 2016; Yarns et al, 2016), meaning discrimination by GPs could increase the likelihood of outcomes like self-withdrawal, self-harm and suicide. These experiences could also discourage patients from accessing general practice services in the future, meaning insufficient attention to various medical and mental health concerns. This highlights the cruciality of general practice staff attitudes toward LGBT+ patients.

Reported variation in GP responses to LGBT+ patients may be due to lack of sufficient training in healthcare. Participants felt that standardised training for GPs around LGBT+ matters delivered across NHS England would benefit patient experiences. Such training could educate on LGBT+ identities and associated medical and mental health considerations. Communication training could also improve staff confidence in discussing topics around gender and sexuality. Poteat et al (2013) found that medical professionals often do not feel confident in their knowledge of LGBT+ matters, particularly in interactions with transgender patients. As a result, some participants in this study experienced dismissal and prejudice by GPs. In such cases, training to improve LGBT+ knowledge and communication is valuable.

Training around LGBT+ matters has been shown to improve knowledge in groups such as medical students (Wahlen et al, 2020), so it is expected to be effective for general practice staff as well. However, training alone may not be sufficient to improve attitudes and responses, as the personal views of general practice staff towards the LGBT+ community may still influence their treatment of patients (Di Lorito et al, 2021). As such, additional challenges must be addressed to improve interactions, including a need for culture change. Culture change could be driven by a top-down agenda within health services, supporting general practice to better address the needs of non-heteronormative patients in their clinical practice. At the organisational level, greater inclusivity could be promoted through welcoming language/imagery in promotional materials, building partnerships with LGBT+ organisations, or even hiring staff who identify as LGBT+ or have experience of working within an equality and inclusion framework (Fredriksen-Goldsen et al, 2018).

This study has several strengths. Participants were from a range of backgrounds and demographics, and they represented various LGBT+ identities, contributing a variety of experiences. While exploration of one specific group within the LGBT+ community may have contributed more detailed data to the specific needs of one subgroup, interviewing the broader group will contribute initial evidence that is much needed in this area. This study also has some limitations. The main one is that it involved a small sample and therefore results should be interpreted with caution as they are not generalisable to the wider LGBT+ community. Conducting interviews remotely could have affected rapport and limited the researcher's observation of participants' body language, for instance. However, participants' comfort due to participating from an environment of their choice could have counteracted any issues potentially arising from face-to-face interviewing (eg feeling uncomfortable or embarrassed). In any case, all interviews began with ‘small talk’ in order to build initial rapport and make participants comfortable.

This study has some implications for future research. Findings of this study contribute to a relatively new area of research. Future research could expand on these findings in a number of ways. Firstly, surveys could be employed to gain a broader view of LGBT+ patients' experiences with general practice staff. Research could also focus on specific identities in the LGBT+ community, such as transgender or intersex individuals, to gain understanding of whether and how various LGBT+ groups are treated differently by GPs. General practice staff could also be recruited to give feedback on their standard of knowledge and ways to improve this.

Conclusions

The study highlighted various experiences and impacts of LGBT+ patients' interactions with general practice staff and has contributed some understanding of how experiences can improve. Participants' recommended improvements emphasise a need for the development and implementation of culture-sensitive NHS-wide training for staff in general practice, which should be accompanied by an organisational agenda supporting more inclusive approaches.

KEY POINTS:

• General practices are usually the first port of call for health-related issues, so the attitudes and behaviours of all staff toward LGBT+ patients can affect their experience and future access to healthcare services
• This qualitative study reported the experiences of six members from the LGBT+ community of general practice appointments
• The participants reported mixed experiences, including recognition and support from staff, but also judgement, prejudice and dismissal
• The participants reported that the negative experiences discouraged disclosure about their identity, treatment outcomes and continued use of services
• Given the diverse range of experiences, this study evidenced a need for standardised NHS-wide training to support staff working in general practice to attend to the needs of LGBT+ patients

CPD reflective practice:

• As a healthcare professional, how do your views toward the LGBT+ community affect your daily clinical practice?
• How can you move from treating all your patients equally to dealing with them differently, based on their unique needs, while still adopting an inclusive approach?
• What can be done to support you to become a (more) confident healthcare professional when dealing with the LGBT+ community?