Sexual & General Health
Guides for GPs and general practice staff
Steps forward
There are a number of low-cost ways in which the practice environment can be made more gay-friendly without alienating other patients.
| Concern about targetting gay men |
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Some GPs may be concerned that acknowledging that gay men remain at high risk of HIV infection may undermine health promotion campaigns seeking to challenge complacency or denial in the heterosexual population. However, the Department of Health's considered view, developed in consultation with expert medical and health promotion specialists, is that it is important, given the current epidemiology of HIV and AIDS to supplement general population education with specific targetting of core risk groups. In a key policy document, An Evolving Strategy they develop guidance that, "it is important not to exaggerate the risks of HIV to the general population, but equally important that everyone recognises that the risks have not gone away." There are five key groups for HIV prevention efforts to target at the present time:
Additionally, it is arguable that overstating the heterosexual risk and understating gay risk will only have the contrary effect of making patients sceptical of all sexual health advice. |
A welcoming environment
- When you next revise your practice publicity, include clear signals that you are happy to discuss sexual health with anyone. Mention that you operate an equal opportunities policy that incorporates sexual orientation.
- You can let it be known that the practice is happy to have gay patients through a careful choice of imagery in the waiting room or in the range of leaflets that are available. You can ask your local gay men's health project for advice about suitable leaflets.
- Display general charters or statements of principle which explicitly include a commitment to equal treatment for all irrespective of sexual orientation.
- Provide clear information about the practice policy on the confidentiality of lifestyle or sexual information kept in patient records.
- Include information acknowledging gay sexuality in updates about sexual health on such occasions as National Condom Week and World AIDS Day. The local health promotion unit can provide help, information and resources for such campaigns.
- Consider the role of receptionists. Your local gay men's health project can provide gay-sensitivity training to staff to help them avoid inadvertently hostile signals.
- Provide openers which give encouraging signals: a "happy to discuss anything that concerns you" approach. This signals to a gay man that his sexuality will not be a problem. One way in which this can be achieved is by incorporating neutral questions into your practice's routine note taking, such as, "do you have a partner?" rather than, "do you have a girlfriend?" With new patients especially, there is very little danger that relationships will be jeopardised by asking questions in ways that do not presume anything about the patient's sexuality. The use of neutral language not only gives the patient permission to ask questions but also signals that it is safe for him to disclose.
- If you run a condom distribution scheme, ensure that some of the condoms available are the stronger ones indicated for anal sex. These will not only send a useful message to gay men but can also be a valuable resource for those heterosexuals who also engage in anal sex.
- If your local gay men's health project are producing new resources it may be possible to be included in a list of services if your practice is proactively gay-friendly. Similarly, you could contact your local gay switchboard and ask if they have a list of 'gay-friendly' GPs and how you may be included in this list.
Assured confidentiality
The best way to reassure not only your gay and bisexual patients, but also others who may have concerns about confidentiality or sexual health, is to show that your practice has addressed the question of confidentiality, reviewed your procedures thoroughly, and then to detail what safeguards you have established.
Policy on confidentiality and record-keeping will vary from practice to practice. Some GPs will take the view that they should record details of sexuality in a patient's notes. Others will choose to be guided by their patient on whether or not he wishes to have such details recorded or not. This principle of negotiated record-keeping has been successfully piloted by some GPs in the Pink Triangle scheme in Leicester.
There are two essential ingredients for all policies if they are to be effective in allaying gay men's concerns about confidentiality:
- Let your patients know your policy on what you do and do not record in their notes. This is useful for everyone but particularly important for gay men who may have a different understanding of what 'lifestyle' information you do or don't need to record.
- Consider putting a detailed explanation of your confidentiality policy in your practice publicity. This should indicate a willingness to discuss the details in private consultation with the patient.
The important thing is that patients know exactly where they stand. They are able to make an informed choice about what to disclose about sexuality or lifestyle in the understanding that most GPs cannot give a 100% guarantee.
Key elements of a confidentiality policy should include:
- what kinds of information are covered by the confidentiality policy
- when and how consent is sought for recording from the patient
- which members of the primary care team have access to a patient's notes on a 'need to know' basis
- how test requests and results (especially of course, for an HIV antibody test) are kept confidential
- how sensitive information recorded in the notes is kept confidential
- clarity about practice policy on responding to lifestyle information requests from insurance companies
- a clear message to the patient about circumstances when you cannot promise confidentiality.
Drafting a written confidentiality policy is a major undertaking. An effective way forward is for a member of your practice to take the lead in shaping policy. Drawing up such a document involves a reasonable amount of consultation (both internally and externally). However, there are several guides which can assist this undertaking. One particularly useful practical toolkit has been produced by a general practitioner in Coventry (see Referrals and Resources).
| Some ways of reassuring your gay patients about confidentiality | |
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| Type of reassurance | Beneficial result |
| A statement about confidentiality can be included in leaflets for new patients. A summary of the confidentiality statement can be included on a poster (in amongst other statements of principle about your practice philosophy or policy) in the waiting room. | The patient who may need to disclose is reassured that your practice has thought carefully about these matters. Other patients are likely to be sympathetic to your declaration of principle too. |
| Terms of confidentiality can routinely be discussed with new patients when they register. A written practice policy on confidentiality can also be given to new patients. | The patient is reassured that the practice hasn't simply adopted confidentiality in principle, but has also put it into practice through staff training. |
| There is a clear statement about practice policy on insurance company or other requests for information about patients' lifestyles. | The patient is reassured because you have re-emphasised the primacy of your responsibility to individual patients. |
| If a patient begins to disclose anything to do with sexual history you discuss with him your policy on what would be written in his notes, if possible before he discloses. | The patient can make an informed decision about what he chooses to reveal. |
| You explain why you need to keep records of particular things such as transmissible infection like Hepatitis B. | The patient is likely to be reassured that your practice is working on a genuine need-to-know basis. |
| You use codes or patient numbers on test request forms. Similarly, you use general infection hazard labels (rather than disease-specific ones in plain view) on the inside cover of the notes. | The patient is reassured that accidental breaches of confidentiality or deductive disclosure are unlikely. |
Gay-appropriate advice
HIV: providing a safety net
There is a high rate of continuing new infection amongst gay men in the UK[25]. However, many studies have shown that most gay and most bisexual men already have a good basic awareness of the risks of HIV and AIDS and the importance of using condoms in anal intercourse[26].
Here are a few ways in which you can assist gay men and provide an important safety net.
It is important to check with each known gay or bisexual patient that he is not one of the exceptions. There are many different ways of putting safer sex on the agenda. A good way to do this might simply be to ask: "What is your understanding of safer sex?" This can initiate a brief discussion in which you can verify that his basic safer sex information is adequate. Many health promotion units can provide training about ways of initiating such discussions.
Depending on the patient, your relationship with him, and the general atmosphere during the consultation, you could offer him some resource to 'update' him with the 'latest information' or you could ask him where he gets his safer sex information from. This could lead into a discussion which he will not find threatening.
It is important to ensure that younger gay men and those who are newly starting gay sexual activity in later life are aware that they may encounter temptation in certain situations: when 'falling in love', in some heat of the moment encounters, under the influence of drugs or alcohol, etc.
In each case, there is generally no need to do more than initiate the process of reflection for your patient and to ensure that he knows about local services that offer literature, workshops, counselling or other safer sex supportive services.
| Resisting stereotypes |
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Sexuality may or may not be the issue in any particular consultation with a gay or bisexual man. There is a balance to be drawn:
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Specific gay-appropriate advice about HIV and AIDS
The HIV epidemic has affected the gay community disproportionately and gay men have had to adapt accordingly[27]. Due to the current epidemic, the historical impact and gay lifestyles, it is important that HIV/AIDS advice you give gay men is specifically designed for them, rather than for generic use.
| Some dos and don't with openly gay patients | |
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| Don't | Do |
 Assume that all your gay or bisexual patients will automatically 'come out' (i.e. disclose) to you. |  Provide a discreet and friendly invitation to disclose. |
| Tell him what you will record in the notes only after he has disclosed important personal sexual information. | Provide information in practice literature about note writing; with openly gay patients this could be restated during the consultation. |
| Make him uncomfortable by seeming to pry into his personal life. | Let it be known that sexual history taking is routine when this is practice policy. |
| Assume that his sexuality is the problem or point of the consultation. | Let him know that you treat every patient equally regardless of sexuality. |
| Try to guess what his experience of the gay HIV epidemic has been. | Provide an opening for him to talk about it at his instigation. |
| Short-circuit into suggesting that he take an HIV test. | Be ready to provide him with information about HIV testing services and/or what the process involves, including confidentiality policy. |
| Assume that what he needs is elementary safer sex education. | Check if he has a workable personal safer sex strategy which he can sustain. |
| Assume that he is either 'monogamous' or 'promiscuous'. | Ask him how he defines his sexual relationships. |
| Assume that you know more about safer sex than he does. | Check that he is confident about putting his personal rules into practice. |
| Assume that he wants you to be an expert on gay lifestyles. | Expect that he simply wants a safe, non-judgemental consultation. |
| Expect him to have the same needs as the previous gay patient. | Let him know explicitly that you are not making assumptions about his needs. |
| Assume that he is comfortable with terms such as 'active' or 'passive' partner. | Check with him what language he feels comfortable using when taking a sexual history. |
| Dismiss a request for Hepatitis A or B vaccination. | Check that he understands: a) what this will and won't protect him from b) the importance of completing the course of three injections. |
| Automatically refer him to other agencies. | Check if he needs, knows and is in touch with sources of community support. |
Resources
Finally, it is important to consider the relevant resources to be able to offer your gay patients.
Condoms and lubricant As previously discussed, if you run a condom scheme it is important to check that the condoms on offer include stronger ones appropriate for anal sex, such as Durex Ultra Strong, Mates Super Strong and HT Specials. In addition to these, water-based lubricant should be provided. Condom-friendly lubricant is now available in sachet form.
Hepatitis A and B vaccination Gay and bisexual men who have sex with a number of different partners run the risk of infection with Hepatitis, a potentially fatal disease, even when they are practising the kind of safer sex that is an adequate protection against HIV infection. There is a safe and effective vaccine, but many gay men are not aware of its importance for their health. The Department of Health's guide to vaccination and immunisation, The Green Book, now recommends that homosexually active men receive both Hepatitis A and B immunisation.
Appropriate leaflets and other reading materials There is a very wide range of free resources available. There are different uses for different kinds of leaflet. For instance it may be possible to display some as an environmental clue in the waiting room, whilst keeping more explicit ones in the consultation room, handing them out when talking about specific sexual practices, as appropriate.
Familiarity with the range of referrals for gay men. This can be easily achieved through meeting with your local gay men's health project or health promotion unit.
Getting help
Most local gay men's health projects understand the importance of the GPs role and will be able to assist with customised training and the identification and provision of suitable resources. And you could invite local gay HIV prevention workers to come in and talk with your practice team.
| Some differences between advice for heterosexuals and appropriate advice for gay men | ||
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| HIV prevention advice often given to the general public | Appropriate HIV advice for gay men | Reason |
| AIDS affects everyone. | HIV and AIDS continue to disproportionately affect gay men. | Prevalence of HIV amongst gay men is between 15 and 50 times what is amongst heterosexuals. |
| Choose sexual partners carefully. | Negotiate carefully in your relationship. A high proportion of HIV transmission between gay men is in relationships. | In a population with high prevalence the chances of even one partner being infected are much higher. |
| Basic awareness raising has been the priority for health promotion and little or no attempt has been made to engage with education about sustaining safer sex under tempting circumstances. | It is a mistake to overprioritise basic awareness raising for gay men. Instead, there is a need for a realistic exploration of lapsing from safer sex and ways of avoiding it. | Gay men know the basic facts already. The problem is how to sustain safer sex over a lifetime rather than lack of knowledge of the risk. |
| Almost all health promotion advice is addressed to the uninfected. | It is important to address sexual health to gay men with HIV as well as those uninfected. | HIV positive men may constitute about 10% of the gay population. |
Reviewing progress
How will you know what has been achieved? There are a number of simple and low-cost ways of monitoring progress. For instance:
- Ask the gay men's health project to monitor any referrals they get from your practice.
- Review how many men are openly gay or bisexual in your practice and any changes over a period of time.
- Review whether the primary care team feels more confident in this area of work.
- Invite any gay men who have disclosed to you to give you feedback about which aspects of the service provided them with reassurance or confidence that they were welcome.
- Review the amount of gay resources that have been distributed to patients.
- Conduct a review or audit of your practice sexual health protocols.
- Review the uptake of Hepatitis vaccination.
- Review referrals to the GUM.