Sexual & General Health

Guides for GPs and general practice staff

What are gay men's concerns?

Not all gay and bisexual men will have the same concerns. After all, they come from all walks of life and all social classes, are young and old, and have varying degrees of self-confidence. However some clear patterns of key concerns emerge[4].

Fear of homophobic rebuff

A fundamental fear of many gay men is that, if they disclose that they are gay, they will receive poorer treatment than if they stay 'in the closet', i.e. if they pretend to be heterosexual. They fear that they will be denied care. Or they may anticipate being made to feel judged or unwelcome in the consultation at a time when they are especially vulnerable.

In reality, most general practitioners are committed to fair treatment for all. For instance, local surveys of GPs have shown an equitable, liberal response to patients' homosexuality[5].

However, it is important for the practice team to remember that no matter how free of prejudice you may be, it may still be rational for gay men to have expectations of inequitable treatment because of a history of such treatment.

Firstly, inequitable treatment is what gay men have grown up to expect from many public services and, indeed, from society in general[6]. Secondly, gay men are aware that hostile or discriminatory attitudes persist among some health care staff[7].

Gay men's concerns can be addressed by a few simple, low key signals that the practice is committed to equality of treatment irrespective of sexual orientation. Gay and bisexual men have grown up keenly attuned to such signals and will respond well to them. Heterosexual patients will hardly notice these signals of goodwill, let alone object to them.

Automatic assumptions about gay men's HIV risk

Epidemiologically, gay men continue to be the group at greatest risk of HIV in the population. However, many gay men will resent any kind of automatic equation between homosexuality and AIDS due to media stigmatisation. As a result they may assume that questioning about their sexual behaviour is ignorant rather than well-motivated.

What this means is that health care professionals may cause offence by giving advice about HIV prevention prior to finding out what a gay man already knows about AIDS and how he applies this to his sex life. As in other aspects of primary care, taking a detailed history is always likely to lead to more accurate diagnosis and effective treatment.

A good example of an area where it is best to 'look before you leap' is that of HIV antibody testing. It is important to understand that some gay men have taken informed approaches to testing. Unlike heterosexuals, only a very few sexually active gay men have never considered HIV testing. Nevertheless gay men report that they sometimes feel pressurised by health care professionals to be tested or even that they have been tested without their consent.

Simple reassurance to allay gay men's concerns without offending other patients
When taking a sexual history, or in a first sexual consultation, ask a man about his partner or partners, rather than wife or girlfriend. Using sensitive, neutral language like this is something that gay men will spot and welcome, but which heterosexual patients won't object to. Include sexual orientation in any statement of equality displayed or published by the practice. Again, the vast majority of heterosexual patients will focus upon other reassuring aspects of such a statement, such as age, ethnicity, gender, culture, class, disability, etc. Gay men, by contrast, will home in on your reassurance about equal treatment regardless of sexuality. Some practices have found that it is immensely reassuring to their gay patients if they display a statement of principle such as this: "In accordance with BMA guidance, the policy of this practice is to treat any lifestyle information our patients give us in strictest confidence and we will not disclose such information to insurance companies or any other third party.[8]"

Simple reassurance to allay gay men's concerns without offending other patients

When taking a sexual history, or in a first sexual consultation, ask a man about his partner or partners, rather than wife or girlfriend. Using sensitive, neutral language like this is something that gay men will spot and welcome, but which heterosexual patients won't object to.

Include sexual orientation in any statement of equality displayed or published by the practice. Again, the vast majority of heterosexual patients will focus upon other reassuring aspects of such a statement, such as age, ethnicity, gender, culture, class, disability, etc. Gay men, by contrast, will home in on your reassurance about equal treatment regardless of sexuality.

Some practices have found that it is immensely reassuring to their gay patients if they display a statement of principle such as this:
"In accordance with BMA guidance, the policy of this practice is to treat any lifestyle information our patients give us in strictest confidence and we will not disclose such information to insurance companies or any other third party.[8]"

Stereotypes about homosexuality

Like most groups, gay men tend to resent the history and continued application of stereotypes. Such stereotypes assume that all gay men are camp or sex-obsessed or that homosexuality is itself some sort of pathology. The persistence of these concerns is not surprising when we consider how recently homosexuality was decriminalised (1967), and that it was removed as a medical condition from registers of mental illness even more recently[9].

A simple rule for avoiding the kind of stereotyping that can jeopardise the doctor-patient relationship is for you to be frank about anything you don't understand. If in doubt it does no harm (and causes no offence) to ask the patient to explain any aspect of gay practice or lifestyle that is unfamiliar to you. Beyond that, Questions and Answers on page 25 of this booklet provides some further insight into the diversity of gay and bisexual men. Finally, training about that diversity is usually available from your local gay men's health project or health promotion unit.

The variety of gay men's approaches to HIV testing
Some have chosen not to be tested on the basis that they practise safer sex with all their sexual partners in any case[10]. Some have chosen not to be tested because they believe they may be positive but would rather not know for the sake of their quality of life. Some have chosen not to get tested because of concerns about insurance companies and mortgages[11]. Some have recently decided to get tested in the wake of the newly available combination therapy, using three or four anti-retroviral drugs, which has begun to show promising results[12]. Some gay couples use testing as part of what has been called a negotiated safety strategy where they don't use condoms within their relationship and either trust each other not to have sex with anyone else or have an open relationship where they agree to only practise safer sex with other, casual partners[13]. Some gay men test a number of times either because of condom failures or following lapses from their own personal safer sex rules[14].

The variety of gay men's approaches to HIV testing

Some have chosen not to be tested on the basis that they practise safer sex with all their sexual partners in any case[10].
Some have chosen not to be tested because they believe they may be positive but would rather not know for the sake of their quality of life.
Some have chosen not to get tested because of concerns about insurance companies and mortgages[11].
Some have recently decided to get tested in the wake of the newly available combination therapy, using three or four anti-retroviral drugs, which has begun to show promising results[12].
Some gay couples use testing as part of what has been called a negotiated safety strategy where they don't use condoms within their relationship and either trust each other not to have sex with anyone else or have an open relationship where they agree to only practise safer sex with other, casual partners[13].
Some gay men test a number of times either because of condom failures or following lapses from their own personal safer sex rules[14].

Concerns about confidentiality

Ever since the beginning of the HIV epidemic, gay men have identified fears about confidentiality as a major barrier between them and their GP[15].

Whereas heterosexual patients don't need to disclose their heterosexuality and don't mind who knows that they are heterosexual, gay men will often feel vulnerable, because they know that, especially in small communities, they may suffer malicious or accidental disclosure and consequential discrimination by third parties.

One of the biggest concerns of gay men will be disclosure of their sexuality to insurance companies. This is not necessarily because they want the insurance policy for its own sake, but because it may seem like an essential prerequisite for getting a mortgage. Nowadays, it is possible for gay men to get life assurance policies, albeit with a heavily loaded premium (irrespective of their personal safer sex practice). However, this has left a historical legacy of concern about 'lifestyle' disclosure. Thus, some gay men will feel unable to talk freely to their GP in case an insurance company one day writes to the GP and asks intimate personal information.

These concerns can, however, easily be allayed by having a clearly communicated practice policy about nondisclosure. The BMA has recommended these examples of appropriate responses you might make to any specific insurance company questions about any of your patients[16]:

Questions about lifestyle "Doctors are advised to avoid invitation by insurance companies to speculate about patients' lifestyle. Doctors may respond to such questions by referring the insurers back to the patient."
Questions about positive HIV status Doctors should answer factually based on records; ensure your patient knows what his record contains.
Questions about prior negative HIV tests Doctors should answer "In accordance with current Association of British Insurers (ABI) policy, I do not disclose details of past negative tests."

Next: concerns of GPs and practice staff

4. The following themes were identified both from focus group work with local gay men and also from studies such as Mansfield (1989).
5. See Newberry (1994) and Rendell (1995).
6. See Zera (1992) for a description of the stresses of coming to terms with one's sexual identity in a society that is openly hostile to homosexuality.
7. This has been indicated in a number of studies including Evans (1993), Gillespie (1993), Wadsworth (1992), Fitzpatrick (1994) and Scott (1997).
8. See the stickers produced by the Sheffield Centre for Sexual Health in Referrals and Resources.
9. For an overview of changing professional views about homosexuality see Mondimore (1996).
10. For a literature review of research on the variety of outcomes associated with HIV antibody testing see Beardsell (1994).
11. This is reflected in leaflets produced by the Terrence Higgins Trust over a number of years as well as BMA guidance. For a full discussion of the issues see Thornton (1996).
12. For a discussion of the new optimism in anti-viral therapy see Issue 48/49, January '97, AIDS Treatment Update.
13. For an insight into some aspects of 'negotiated safety' see Kippax (1993).
14. See Coxon (1996).
15. See for instance King (1988), Mansfield (1989) and Wadsworth (1992).
16. See Curtis (1995) and Thornton (1996).