Sex and Sexuality

including LGBTQ+

First of all, don't be scared about talking about sexual issues

If you’re embarassed, apprehensive or worried about talking around sexual issues, then this will come across in the consultation and the patient will sense this and you will then make them feel uncomfortable too.   So, try and be a bit more confident about talking around sexual issues.   Some simple rules are…

  • Don’t talk to a 40 year old man about his wife or a 16 year old girl about any boyfriends.
  • Use the word partner.   “Do you have a partner?”   Then you can use a suplementary question like “Is your partner male or female?”.   
  • Or you can say “thanks for tell me about that.  Can I ask whether you have a boyfirend or girlfriend?”
  •  If you need to know specifics, gather that specific data!
  • This is a common mistake GP trainees make in the CSA.  They are too “nice” with their language and in so doing, do not gather exact data to help them with clinical decision making.
  • So, instead of “when it happened did you engage safe sex?” say “so during sex, did you use a condom?”
  • 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?”
  • Sometimes, depending on the level of understanding of that patient, you may need to use even more simple language than anal or oral sex.  You may need to use words like “bum sex” or “blow job”.  It really does depend on the level of understanding of the patient.  Most know what oral and anal are, but you will come across someone with whom you will need to use more simple and explicit language.  
  • At the end of the day, you need to know exactly what went on in order to establish medical risk of STDs, pregnancy etc.
  • Sex Worker is kinder and more likely to help patients open up.
  • Instead of “and have you had sex with a prositute or anyone like that recently?” say “have you had any form of sexual encounter with a sex worker?”
  • Then clarify – don’t assume the sex worker was female!   “Thank you for telling me that.  Was that sex worker male or female?”
  • You may need to ask more clarifying questions.   “In that time, was there more than one sex worker?”,  “So you said one was female, what about the others?”
  • And if you want to be really help patients feel relaxed and tell you about things that they might be embarassed about, try and normalise their behaviour to help them see that they’re not alone and therefore shouldn’t feel too embarassed.   Something like “So, you’re worried about this discharge from your penis.   And you mentioned you went abroad. Sometimes, when people go abroad, they end up have sex with either people they meet or with sex workers abroad.    Is that something that has happened to you?”
  • Many couples are in a happily open relationship    This applies to both gay and straight couples.  You may be surprised at this because it’s not something people go around advertising!   They’re are couples who clearly love each other but prefer to spice up their sex life either by sleeping with others – either separately, together or both.    It’s common in both straight, gay and bi communities.  Straight couples who do this are often referred to as Swingers.   Do not use this word though as it can be seen as judgemental and derrogatory.
  • Don’t judge couples who have an agreement with each other to sleep around.   If it helps keep their relationship alive – who are you to judge?   Don’t forget, the key to a successful relationship is usually great companionship and love rather than sex!  Why should a couple split up if they still love each other dearly, love each other’s companionship but the sex has gone a bit dry?
  • DON’T say “so are you both committed and loyal to each other” – which kind of says you are judging them as bad if they say they are not and it is more likely they will not open up to you.  Instead, remain neutral and ask… “Okay, so it sounds like both of you are having some symptoms down below.   Some couples who love each other sometimes agree to have sex with others.   Can I ask if either of you have this type of arrangement?”
  • If you apologise for asking, it is like you saying that what you’re asking about is wrong, sinful or bad.     You are not in a position to make such a statement.  You are a doctor.  Patients come to see you in your role as doctor.
  • So, DON’T say to a 35 year old man “I’m sorry to ask you this but it is a routine question.   Are you gay or slept with other men”.   Equally DON’T say “Can I ask, have you had any sexual encounters with men?…. Thanks for that, sorry to have to ask but I have to ask these sorts of things.”
  • DON’T say “I’m sorry to ask but do you sleep with sex workers”
  • DON’T say “I have to ask this question, are you both committed and loyal to each other?”.   DON’T say “do either of you sleep around”
  • Instead, just say it in a way that is neutral and shows no judgement.    “Thanks for telling me that.  Can I ask, is you partner male or female?  Okay.   And some couples who have a healthy relationship have an agreement to be in an open relationship.  Are either of you in an open relationship?….    Thanks for being so honest with me.”
  • It’s okay not to be totally familiar with the LGBTQ+ culture.   Equally, it’s okay not totally understand what binary and non-binary actually means.  And it’s okay to be confused with words like gender-fluid.
  • What is NOT okay is to be judgemental about them!
  • Show that you want to help and apologise for your lack of knowledge but your willingness to learn.   “Thank you so much for sharing with me that you are non-binary.    I really want to help you as much as I can.   I am sorry for not really knowing much about non-binary people.  Would you mind helping me to understand it better so I can help you in the best way I can?”

I am an International Medical Graduate. Sex is a taboo subject and we don't talk about it much in my country

  • In the UK, talking about sex is still a taboo subject but no where near as much as in the 1970’s, 80’s or 90s’.  We are becoming more open a society and better at talking about such things.   The future will be certainly even more open!
  • You have chosen to practice in the UK, so you have to change your attitude and behaviour to fit in with the society you are serving here.   
  • Besides, if you don’t, then the data you will gather will be incomplete and this will lead you to make incorrect diagnoses, conclusions, and clinical management plans.  Do you want to live with this medical risk?
  • But there is a better way.  Even though it is taboo in your home country, why not develop and learn the skills to be able to deal with it?   Why not skill yourself up to be a better you?    And why not take control so that you know you have skills to help you gather the right data set to make safe clinical decisions?
  • This means talking about this area a lot with your GP trainer, fellow trainees, health professionals and patients you come across.    Don’t worry about making mistakes in your language.  Mistakes help you to learn.
  • As a starter, why not do some practice CSA cases on Sex and Sexuality with your GP trainer and your GP trainee peers?   There are a lot of good CSA case books out there.

What does LGBTQ+ mean?

  • LGBTQIA is the inclusive queer term which stands for lesbian, gay, bisexual, transgender, queer and/or questioning, intersex and asexual and/or allies.
  • While terms like this attempt to acknowledge many different groups, it’s worth noting that the LGBTQIA community is arguably not one group, but rather it is made up of many separate subsects not all in agreement on all terminology.  PLEASE DO NOT LUMP ALL THESE DIFFERENT GROUPS TOGETHER – the term is an inclusive one to show that there is a wonderful diversity in the human race rather than the old straight-gay-bisexual world-view.
  • LGBTQIA refers to specific parts of the community, while sometimes subsects are grouped under the umbrella term “plus” in the acronym LGBTQ+.
  • This represents sexual identities other than lesbian, gay, bisexual, transgender and queer or questioning, including pansexual, asexual and omnisexual.

What does + bit mean?

The “plus” is the least obvious part of the LGBTQ+ initialism, and stands for those who aren’t questioning their sexuality, but identify as part of a group that might not be so well known or understood.

Many of the terms confuse me...

Here are some terms that aren’t so commonly understood.  We hope this demystifies it.

  • Pansexual:
    Somebody who identifies as pansexual experiences feelings of attraction (physical, emotional or sexual) towards more than one gender identity. Similarly, omnisexual people can be attracted to all genders, although they can tend to date a higher percentage of one certain gender.  Sometimes, pansexual people will refer to themselves as “gender-blind”.
  • Asexual:
    A person who identifies as asexual typically experiences little or no sexual attraction to anyone else. The asexual scale can differ from those who have a low sex drive, to those who don’t desire sex whatsoever.
  • Straight allies:
    The affectionate term given to friends of the LGBTQ+ community who aren’t a part of it. For example, straight-identifying people who support LGBTQ+ rights and queer culture. Allies are important because of the influence they can have over other straight people who may not have such a deep understanding of the issues affecting the queer community. In this way, allies can be a bridge between communities.
  • Intersex:
    A person who is born with variations in sex characteristics including chromosomes, gonads, sex hormones, or genitals that don’t fit the typical ‘male’ or ‘female’ definitions. This can include genital ambiguity. Intersex people, like everyone, can identify as any gender.
  • Cisgender:
    The opposite of a transgender person – that is, someone who identifies as the gender they were assigned at birth.
  • Gender-fluid:
    People who are aware of the flexibility of their own gender, and may change their gender throughout their life

Please read the document "Avoiding heterosexual bias in language"

It’s a wonderful document that will demonstrate how many doctors (and other professions) talk in a way that has a strong heterosexual bias.   For example, asking a female patient “and what does the husband says” might put them off from disclosing to you that they are bisexual and currently with a female partner.  The document provides some amazing alternative phrases that are more inclusive.  This will no doubt help build your consultation skills for the better. 

My religion does not agree with it

Most religions have come to the sensible realisation that we are all God’s people and that we are all equals in the eyes of God.  If you still feel that your religion does not agree with it, you may wish to talk about it in your small group at Half Day Release and see what others feel.  Please remember to treat individuals as individuals and allow them the right to express themselves freely  just like the way others allow you to express the way you are.

The GMC’s “Good Medical Practice” – domain 4 (which is about TRUST) says under article 54:
Show respect for patients: You must not express your personal beliefs (including political, religious and moral beliefs) to patients in ways that exploit their vulnerability or are likely to cause them distress.

This means that you must put your personal beliefs to one side and treat individuals with equal respect and do your best for them just like you would do with any other patient.   Furthermore, one could argue that if you don’t respect nor value the rights of LGBTQ+ people, then that is kind of saying that you don’t value nor see the colourfulness of diversity, and neither do you believe in equality between your fellow brothers and sisters.  What are your thoughts?

Please leave a comment if you have a tip, spot an error, spot something missing or have a suggestion for a web resource.
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