BMJ  2004;328:1211-1212 (22 May), doi:10.1136/bmj.328.7450.1211

Editorial

Disclosure of sexual preferences and lesbian, gay, and bisexual practitioners

"Informed consent" needs to be balanced against "freedom from discrimination"

In the public mind doctoring and homosexuality do not sit easily together. More than most occupations, medical practice is affected by powerful cultural stereotypes concerning the social identity of practitioners. As part of their work doctors have privileged access to their patients' bodies, and in return patients expect to know something of the social and moral character of the practitioner. In popular culture doctors have been represented as asexual or heterosexual, but rarely as a group that includes people who may have same sex relationships. We do not know how many health professionals self identify as lesbian, gay, and bisexual. Extrapolating from estimates for the general population, many commentators have quoted the figure from the American Kinsey studies of about 10%, although a recent national survey in the United Kingdom showed that only about 5% of both men and women had ever had a same sex partnership.^{1 2} The existence of the Gay and Lesbian Association of Doctors and Dentists in the United Kingdom and the Gay and Lesbian Medical Association in the United States implies that considerable numbers of professionals are involved.

Lesbian, gay, and bisexual practitioners feel vulnerable. Studies in north America and Britain report that lesbian, gay, and bisexual doctors and medical students encounter homophobic behaviour from both professional colleagues and patients.^3-5 In Britain the right of lesbian, gay, and bisexual doctors to practice without discrimination has been recognised in guidance from the General Medical Council, and recent legislation makes it unlawful for employees to be treated less favourably because of their sexual orientation.^{6 7} But how far these measures have swept away homophobic attitudes is unclear. Little research exists on the pressures affecting lesbian, gay, and bisexual professionals, and how they manage working relationships.

A paper in this issue by Daniel Riordan is the first in a major journal that reports on how a group of lesbian, gay, and bisexual healthcare professionals adjusted to the demands of everyday practice.⁸ The sample was initially recruited through the Gay and Lesbian Association of Doctors and Dentists, but Riordan widened the inquiry to include two nurse practitioners and a physiotherapist as well as medical practitioners in a range of settings. This is quintessentially a study of a sensitive topic, with all the attendant problems of identifying and recruiting respondents that arise in this kind of research. Although it is a small study, relying on a (non-random) snowball sample, it offers a snapshot of an aspect of health care that we could probably not obtain in any other way.

The finding that lesbian, gay, and bisexual practitioners are deeply preoccupied with issues of managing their identity will not surprise readers who are familiar with the literature on social identity and stigma. Although health professionals may resolve in advance either to be open about their sexual orientation (to "out" themselves) or to avoid disclosure (by trying to "pass" as normal), it would be unrealistic to think that every routine consultation could be prefaced by an explanation of sexual preference. Most practitioners find themselves carefully negotiating their way through interactions, making decisions from one moment to the next about how relevant their sexual identity may be to the situation and just how open to be. Thus in a single day a gay doctor might find himself "passing" to avoid homophobia but also revealing his homosexual identity to show affinity with a gay patient, or as a desexualisation strategy to resolve problems in examining a woman patient. "Passing" may involve conformity with self protective routines based on cultural assumptions of heterosexuality, like the use of chaperones for female patients examined by male doctors. Many lesbian, gay, and bisexual practitioners follow this practice despite the sense of irony that it engenders. This movement between different personas can generate real tensions as, for example, professionals ponder what will happen if attempts to "pass" are undermined by the subsequent discovery of sexual preference.

At just what point lesbian, gay, and bisexual identity becomes relevant to the interaction and needs to be disclosed is not straightforward. My guess would be that a substantial number of patients expect this information to be communicated before a physical examination is carried out. Lesbian, gay, and bisexual practitioners face the difficult talk of constructing a version of ethical practice, which balances the principle of informed consent against freedom from discrimination. As Riordan says, very little exists in the medical school curriculum or in continuing professional education that helps prepare lesbian, gay, and bisexual practitioners to chart a course through these dangerous waters.

Accounts of qualitative interviews are not simple reports of facts but often statements of individual perspectives and the moral realities recognised by respondents. Documenting the actions and perspectives of groups who are not well understood by mainstream society is an important but complex task for research. We know from other research on social identity that respondents are likely to report problems and coping strategies that are acceptable within particular communities, and de-emphasise those that are seen as more difficult.^{9 10} For example, an implicit message from Riordan's study is that homophobia is a problem mainly in dealings with patients rather than fellow professionals. This may support earlier research, which shows that over time professionals have become more accepting of lesbian, gay, and bisexual colleagues but which could also reflect reluctance to talk about a painful issue.¹¹ Clearly, we need a larger dataset before we can be sure about this and other matters of detail. In the meantime, exploratory research like that of Riordan can play a valuable role in widening professional awareness of a taboo subject and suggesting hypotheses for further investigation in larger, more systematic studies.

Centre for Health Economics and Policy Studies, School of Health Science, University of Wales, Swansea SA2 8PP (d.hughes{at}swansea.ac.uk)

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Papers p 1227

Competing interests: None declared.

References

1. Kinsey AC, Pomeroy WB, Martin CE. Sexual behaviour in the human male, 1948. Philadelphia: WB Saunders.
2. Johnson AM, Mercer CH, Erens B, Copas AJ, McManus S, Wellings K, et al. Sexual behaviour in Britain: partnerships, practices, and HIV risk behaviours. Lancet 2001;358: 1835-42.[CrossRef][ISI][Medline]
3. Rose L. Homophobia among doctors. BMJ 1994;308: 586-7.[Free Full Text]
4. Parker A, Bhugra D. Attitudes of British medical students towards male homosexuality. Sex Relationship Ther 2000;15: 141-9.[CrossRef]
5. Risdon C, Cook D, Williams D. Gay and lesbian physicians in training: a qualitative study. CMAJ 2000;162: 331-4.[Abstract/Free Full Text]
6. General Medical Council. Duties of a doctor, good medical practice. London: GMC, 1995. www.gmc-uk.org/standards/good.htm (accessed 17 May 2004).
7. The Employment Equality (Sexual Orientation) Regulations 2003. www.hmso.gov.uk/si/si2003/20031661.htm (accessed 17 May 2004).
8. Riordan DC. Interaction strategies of lesbian, gay, and bisexual healthcare practitioners in the clinical examination of patients: qualitative study. BMJ 2004;328: 1227-9.[Abstract/Free Full Text]
9. Voysey M. A constant burden. London: Routledge, 1975.
10. Baruch G. Moral tales: parents' accounts of encounters with the health profession, Sociol Health Illness 1981;1: 275-96.
11. Burke BP, White JC. Wellbeing of gay, lesbian, and bisexual doctors. BMJ 2001;322: 422-4.[Free Full Text]

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