Sex, Sexuality & LGBTQIA+ Communication

GP practices with Pride in Practice accreditation report:

• Increased patient satisfaction scores among LGBTQIA+ patients
• Higher rates of sexual health screening uptake
• More patients voluntarily disclosing sexual orientation and gender identity
• Reduction in complaints related to discriminatory language
• Staff feel more confident handling consultations with LGBTQIA+ patients

MSM is a BEHAVIOURAL term, not an identity.

Many men who have sex with men do not identify as gay or bisexual. They may:

• Be in relationships with women
• Be sexually attracted to women but also have sex with men
• Not want a romantic relationship with men
• Identify as straight despite same-sex sexual behaviour

Why this matters in GP: When asking about sexual health risk, ask about behaviour ("Do you have sex with men, women, or both?"), not identity ("Are you gay?"). You'll get more accurate information for clinical decision-making.

This is a common mistake GP trainees make in the SCA. They are too "nice" with their language and in so doing, do not gather exact data to help them with clinical decision making.

Examples of being too vague:

DON'T say "so you had normal sex?" — it's a bad question. You need to know specifics. Besides, what is normal sex? Is other sex abnormal?

So, say something like: "So, when you say sex, do you mean vaginal sex, anal sex, oral sex or a combination of?"

"Okay, so it was a combination — can I ask exactly what?"

✅ Good responses:

• "Thank you for sharing that with me. I want to make sure I understand — would you mind helping me understand what non-binary means for you?"
• "I really appreciate you being open about that. I want to support you properly — can you help me understand what that means in terms of how I should refer to you?"
• "Thank you. I want to get this right — what pronouns should I use?"

❌ Poor responses:

• "Oh, I don't really know what that is" (dismissive tone)
• "Right, okay" [then proceed to ignore it]
• "That's interesting" [without follow-up]
• Making assumptions and not asking at all

✅ Good responses:

• "Thank you for telling me. I want to make sure I understand — can you help me understand what that means for you?"
• "I appreciate you sharing that. So I can support you best, would you mind explaining a bit more about that?"
• "I want to make sure I get this right — can you tell me a bit more about what that means in terms of your relationships or attractions?"

✅ Good responses:

• "Can you tell me a bit more about your partner?" (open-ended)
• "What pronouns does your partner use?" (if relevant to clinical context)
• Just wait — most patients will naturally provide this information if it's relevant

If clinically necessary to know gender:

• "Is your partner male or female?" (asked matter-of-factly, in context of sexual health risk assessment)

Purpose: Create immediate psychological safety so patients feel comfortable being honest

Effective opening phrases:

• "How can I help you today?"
• "Tell me what's been going on."
• "What's brought you in to see me?"

If discussing sensitive topics, signal confidentiality early:

• "Before we start, I just want to remind you that everything we discuss is completely confidential."
• "This is a safe space to talk about anything that's concerning you."
• "I ask all my patients these questions — they're part of getting a full picture of your health."

Purpose: Understand social context without making assumptions

Initial questions (gender-neutral):

• "Are you in a relationship at the moment?"
• "Do you have a partner?"
• "Can you tell me about your relationship situation?"
• "Who do you live with?" (for social history)

Follow-up clarification (if clinically relevant):

• "Is your partner male or female?" (asked matter-of-factly, not apologetically)
• "Can you tell me a bit more about your partner?" (lets them volunteer information)

For sexual health contexts:

• "In the last few months, have you had sex with one partner or more than one?"
• "Do you have sex with men, women, or both?"
• "Some people have relationships where they've agreed they can have sex with other people. Is that something that applies to you?"

Purpose: Signal inclusivity and avoid misgendering

Best practice: Ask everyone, not just people you "suspect" are trans

• "What pronouns do you use?"
• "What pronouns should I use for you?"
• "My pronouns are she/her. What are yours?"

If you need to ask about gender identity specifically:

• "What is your gender identity?"
• "How do you identify in terms of gender?"
• "I notice your records show [X]. Is that how you identify?"

If records and presentation don't match:

• "I see your records show [legal name]. Is there a different name you'd prefer me to use?"
• "What name would you like me to call you?"

Purpose: Understand actual risk, not assumed risk based on identity

Don't ask: "Are you sexually active?" — too vague

Do ask specific questions:

• "Are you currently having sex?"
• "Do you have sex with men, women, or both?"
• "Can you tell me what types of sex you're having — vaginal, anal, oral, or a combination?"
• "When you have sex, do you use condoms?" (not "do you practice safe sex" — too vague)
• "Have you had any sexual partners in the last 3 months?"

If exploring specific exposures:

• "Have you had any sexual encounters with sex workers?" (then ask: "Were they male or female?")
• "Sometimes when people go abroad, they end up having sex with people they meet or with sex workers. Is that something that's happened for you?"

Normalising questions helps patients answer honestly:

• "I ask everyone these questions because they help me understand what tests or advice might be helpful."
• "These questions might feel quite detailed, but they're important for making sure we're looking after your health properly."

Purpose: Respond with affirmation, not surprise or discomfort

If a patient discloses their sexual orientation:

• "Thank you for sharing that with me."
• "I appreciate you being open about that — it helps me understand how best to support you."
• "That's helpful to know. How can I best support your health?"

If a patient discloses their gender identity:

• "Thank you for telling me. What pronouns do you use?"
• "I appreciate you sharing that. Is there anything specific you'd like me to be aware of in how I support you?"
• "Thank you. Would you like me to update your records to reflect that?"

❌ NEVER say:

• "Oh! I didn't realise!" (sounds surprised)
• "You don't look gay/trans" (offensive)
• "My friend/relative is gay too!" (irrelevant and patronising)
• "That's so brave of you to tell me" (makes it seem unusual or difficult)
• Asking questions out of curiosity rather than clinical need

Purpose: Demonstrate genuine human connection and validation

When patients express fear or worry about discrimination:

• "I want you to know this is a safe space. You can be completely open with me."
• "I'm sorry you've had negative experiences elsewhere. That shouldn't happen."
• "Your sexual orientation/gender identity doesn't change the quality of care you deserve."

When patients express distress related to identity:

• "That sounds really difficult."
• "I can understand why that would be upsetting."
• "It makes complete sense that you're feeling this way."

When patients describe rejection or discrimination:

• "That must have been incredibly hard."
• "I'm sorry you've experienced that."
• "You deserve support, not judgment."

For sexual health:

• "If you develop any symptoms like discharge, pain when urinating, or sores, please come back straight away."
• "We should retest in 3 months to make sure the infection has cleared."
• "If you're planning to have sex without condoms with a new partner, it's worth both getting tested first."

For mental health related to identity:

• "If things feel overwhelming at any point, please come back. We can support you through this."
• "Here are some LGBTQ+ specific support services that might be helpful." [provide details]
• "If you're experiencing thoughts of self-harm or suicide, please contact [crisis services] or come back urgently."

For trans patients awaiting gender services:

• "I know the waiting times are very long. Please come back at any point if you need support while you're waiting."
• "We can look at what support might be available in the meantime."

What's happening: They may be processing trauma, rejection by family, discrimination, or the relief of finally being able to talk about this

✅ What to say:

• "Take your time. There's no rush."
• "I can see this is really difficult for you."
• "It's okay to take a moment. Would you like a tissue?"
• [After they've composed themselves] "Thank you for trusting me with this."

❌ Avoid:

• "Don't cry" or "It's okay, don't get upset" (invalidates their emotions)
• Rushing to move on (gives message you're uncomfortable)
• Over-reassuring before you understand the problem

What's happening: They might be testing whether you're safe before opening up fully, or they've experienced discrimination before and expect it from you

Example: Patient says bluntly, "I'm gay. Is that going to be a problem for you?"

✅ What to say:

• "Not at all. Thank you for telling me — it helps me understand your health better."
• "No, and I'm sorry if you've had experiences that made you feel you needed to ask that."
• "Absolutely not. This is a safe space for you to be completely open."

Then continue matter-of-factly:

• "So, you mentioned [returning to their presenting complaint]..."

What's happening: They may have faced discrimination elsewhere, feel their privacy is being invaded, or be frustrated with healthcare systems

Example: You ask about partners and they snap, "Why does that matter? What's my relationship status got to do with my chest pain?"

✅ What to say:

• "That's a fair question. I ask everyone about their social situation because it can affect health and wellbeing. But if you'd rather not discuss it right now, that's absolutely fine."
• "I can hear that you're frustrated. I'm asking because [specific clinical reason if there is one], but I don't need to know this to help you today."
• "I understand. Let's focus on what brought you in today."

❌ Avoid:

• Getting defensive
• "I have to ask these questions" (sounds confrontational)
• Pushing when they've clearly indicated discomfort

Example: "I'm worried you'll judge me" or "I've had bad experiences with doctors before"

✅ What to say:

• "I'm sorry you've had those experiences. That shouldn't have happened."
• "This is a safe space. I'm here to help, not to judge."
• "I really appreciate you giving me the chance despite those experiences. I'll do my best to support you."
• "Everyone deserves respectful, high-quality healthcare. That includes you."

Then demonstrate through actions:

• Use inclusive language consistently
• Take their concerns seriously
• Don't probe unnecessarily into their identity out of curiosity
• Keep promises (e.g., if you say you'll call with results, call)

Current Reality (as of 2026):

• Waiting times for NHS gender identity clinics: typically 3-5+ years
• Patients can be referred to any GIC in England — check waiting times vary by location
• New pilot clinics launched (Indigo Gender Service in Manchester, CMAGIC in Merseyside, TransPlus in London areas)
• Many patients access private care while waiting for NHS — may request shared care agreements

Bridging Prescriptions:

GMC advises GPs may consider bridging prescription of hormones when:

• Patient is self-prescribing or likely to self-prescribe from unregulated sources
• Prescription aims to mitigate risk of self-harm or suicide
• GP has sought advice from gender specialist
• Prescribing lowest acceptable dose

This is a complex area — seek advice from specialists and your medical defence organisation