This is a plain English summary of an original research article
Recommendations from research could improve communication between clinicians and people who are lesbian, gay, bisexual, and transgender (LGBT+). A study found that LGBT+ people who were seriously ill, and their significant others, appreciated neutral language that does not make assumptions, and questions about identity that are relevant to care. They valued signs of LGBT+ inclusivity in organisations.
The NHS has a legal and ethical duty to reduce health inequalities, but LGBT+ people continue to report discrimination and exclusion. This is partly due to poor communication between clinicians and patients.
In this study, researchers interviewed LGBT+ people who were seriously ill, their significant others, and clinicians. They found that clinicians want to provide inclusive care but are often unsure how to talk about sexual orientation and gender.
The researchers used their findings to develop practical guidance to improve communication between clinicians and LGBT+ people. Though the patients interviewed were seriously ill, the recommendations are relevant to all patient-clinician interactions.
The issue: the need for better communication with LGBT+ people
Around 8% of people identify as lesbian, gay, or bisexual and 1% identify as transgender or non-binary (where gender is not fully captured by either ‘man’ or ‘woman’). LGBT+ people continue to report discrimination and exclusion in health and social care.
People who experience and anticipate discrimination can take longer to seek medical help. This delay is linked to higher rates of serious illness (such as cancer), poorer health outcomes, and risky health behaviours (such as smoking and drinking). However, the specific needs of LGBT+ people are not always included in mandatory medical training or embedded meaningfully in hospital policies and systems.
Assumptions made by clinicians about people’s gender and sexual orientation can undermine relationships and lead to a loss of trust. It may be particularly damaging for seriously ill LGBT+ people, and their significant others, who may in turn feel unable to share aspects of their identity. Skilled communication is central to inclusive, person-centred care.
A study explored LGBT+ people’s experiences and preferences for communication in healthcare relating to sexual orientation, gender identity and gender history. It also explored the experiences of their significant others and clinicians to understand all perspectives, and improve interactions for better care.
The study included 34 seriously ill LGBT+ people, 13 significant others, and 27 clinicians (including doctors, nurses and social workers). Most were in Greater London. Researchers asked LGBT+ people how their sexual orientation and gender had been included in their interactions with clinicians, and how that could be improved.
Three themes, and 10 recommendations, were generated from the interviews.
A positive first impression
All participants valued appropriate terminology, and avoiding incorrect assumptions. One non-binary person spoke about clinicians referring to their gender incorrectly: “It springs up this image in people’s minds that isn’t me.” Many people were sensitive to non-verbal signs. A patient said: “When I say, ‘lesbian,’ … I’ll look for a little micro-expression… I can almost read, okay, you’ve taken that on the chin, I respect that...”
Incorrect assumptions force LGBT+ people to decide whether to correct the clinician. One nurse said LGBT+ people may think “Is it safe to disclose or not? Do I have to come out? Do I want to come out?”.
- Neutral language that does not make assumptions about people’s identity can put people at ease.
- Using the same words patients and their significant others use to describe themselves will avoid giving the impression you object or are not listening.
- Your body language, tone, pitch and volume of speech can suggest surprise or disapproval.
Open and sensitive communication
Some clinicians were anxious not to offend patients by asking about gender identity and sexual orientation, but delaying these conversations can make them more difficult to have. People felt that clinicians sometimes lacked clarity in such discussions. A transgender patient said: “Do you need to know when I started on hormones? Do you need to know about any surgeries that I’ve had? Like these are the things that I think you are trying to ask but actually you need to ask them specifically…”
Many interviewees spoke about how to include significant others in discussions about their care. One clinician said, “I’ll say ‘Who’s most important to you? Can I contact them to offer support?’ and most people are grateful.”
- Questions that are relevant to care are more acceptable; people need to be given the option not to provide an answer.
- Respect for gender identity and correct use of pronouns supports clinician-patient relationships.
- Inquiring about any significant others using neutral pronouns, and including them in discussions where appropriate, is appreciated.
- The environment matters; drawing a curtain does not provide privacy and people do not want personal information about sexual orientation or gender disclosed without their permission.
People valued clear and consistent LGBT+ inclusiveness. Having the same discussions with everyone took away the fear of offending anyone. This could be especially helpful for people who are older, religious, or have black, Asian or ethnic minority backgrounds. A clinician said: “I know that culturally, you know sort of black and ethnic minority people, it’s very difficult for them to be gay, and it can be very, very taboo…”
Some people were concerned that changing their medical records may impact care: “[T]he NHS has a huge blind spot…if you change your gender identity to female because you’re a trans woman, you won’t get called for prostate screening.”
- Standard questions put to all patients about sexual orientation and gender can provide a structure to discussions and reassure LGBT+ people that they are not being singled out.
- Systems that enable accurate recording in medical notes of details about people’s identity (with their permission), could support appropriate care and avoid needing to broach the topic repeatedly.
- Visible signs of inclusivity such as rainbow badges and lanyards were valued by LGBT+ people.
Why is this important?
This is the largest qualitative study on communication about gender and sexual orientation in healthcare to include LGBT+ patients, significant others and health and social care professionals. The recommendations will help clinicians have inclusive discussions about identities and relationships in everyday practice.
Some people may be reluctant to engage with these conversations. But avoiding discussions may increase health inequalities for LGBT+ people.
This study is one of several ACCESSCare research projects, which aim to improve care for LGBT+ people experiencing serious or advanced illness, end-of-life care, or bereavement.
The researchers used these findings to develop a practical guide on LGBT+ inclusive communication for health and social care professionals. They worked with LGBT+ community members and clinicians to refine the guide. A set of posters, which illustrate some of their recommendations, are also available on request. They hope their recommendations will be implemented and evaluated.
Hospitals, other healthcare organisations and healthcare educators could support clinicians by providing training on inclusive communication practices, the researchers say. Systems could be updated to allow clinicians to share information about people’s sexual orientation and gender (where they have consented) so that these conversations only need to happen once.
Few transgender (8) and bisexual people (3) participated, so their views may not be fully captured in the study. In addition, most participants were from London, so the findings may be different elsewhere. More research is needed in all of these groups.
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This Alert is based on: Braybrook D, and others. Communication about sexual orientation and gender between clinicians, LGBT+ people facing serious illness and their significant others: a qualitative interview study of experiences, preferences and recommendations. BMJ Quality and Safety 2023;32:109-120.
A practical guide on inclusive communication for LGBT+ people was developed from this research.
A guide for LGBT+ people on palliative care.
Information from the NHS about tackling poor outcomes and experiences of LGBT+ people in healthcare.
Funding: The study was funded by the NIHR Research for Patient Benefit Programme and was supported by the NIHR Applied Research Collaboration South London.
Conflicts of Interest: The researchers had no relevant conflicts of interest.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.