Guidelines for the Primary Care of Lesbian, Gay, and Bisexual People: A Systematic Review

We are very pleased to note the review published by McNair and Hegarty of the available guidelines for the care of LGB people in primary care, and strongly endorse their call for evidence-based recommendations to be specifically produced for primary care settings. We are particularly pleased to note their suggestion that such guidelines be widely distributed and regularly updated in order to account for the changing social and political context of LGB people’s lives in these diverse settings.

Our recent research on depression in gay-identified and other homosexually- active men attending general practices in both urban and regional parts of Australia confirmed the high rates of major depressive disorder in this population,1 but also recognised that these high rates are most significantly associated with social factors such as socio-economic hardship, interpersonal isolation and personal withdrawal.2 This provides further evidence of the health inequities affecting many gay men, and their ongoing experience of marginalisation and discrimination in a diverse range of social contexts. Primary health care service providers – including general practitioners (GPs) in Australia – play an essential role in supporting their LBG patients and addressing these inequities.

Our research also suggests that there are issues that arise in the primary care of gay men that GPs can find difficult to respond to, particularly issues relating to recreational drug use3 and sexual practice.4 However, while recognising that it can indeed be challenging for some clinicians to develop confidence in raising and responding to these issues, the GPs who are most regularly engaged in the care of gay men in our Australian research have been shown to develop strong capacities in this regard, which ultimately then strengthen their treatment of associated health and psychosocial issues, including the more effective diagnosis5 and management6 of depression. It should be noted here, that because of the smaller amount of research that is conducted with lesbians, less is known about lesbian experiences of depression and the comorbidities associated with depression in this population.

Finally, we would like to take the opportunity to suggest that qualitative research should also be taken into account in developing guidelines for the primary care of LBG people. Qualitative methods do not fit easily within current frameworks for the evaluation of research evidence, mostly because their data is closer to the form of stories than numbers and because it does not aim to provide evidence that is ‘generalisable’. However, qualitative research can provide important, and often essential, evidence of how health is experienced, understood and practiced among LGB people, and among the health professionals who care for them.7

One area in which qualitative research is particularly valuable in this regard relates to doctor-patient relationships, including the expectations that LBG people themselves may bring to clinical encounters in general practice and other primary care settings, and how these might reflect or diverge from clinician perspectives.8-9 Through this and related approaches, qualitative research has an important role to play in strengthening our understanding of what works in the primary care of LBG people.

References

1. Mao L, Kippax SC, Newman CE, et al. Rates of depression among men attending high HIV caseload general practices in Australia. Mental Health in Family Medicine 2008;5(2):79-83.

2. Mao L, Kidd M, Rogers G, et al. Social factors associated with Major Depressive Disorder in homosexually active, gay men attending general practices in Australia. Australian and New Zealand Journal of Public Health. 2009;33(1):83-86.

3. Saltman DC, Newman CE, Mao L, et al. Experiences in managing problematic crystal methamphetamine use and associated depression in gay men and HIV positive men: in-depth interviews with general practitioners in Sydney, Australia. BMC Family Practice. 2008;9(1):45.

4. Mao L, Newman C, Kidd M, et al. Self-reported sexual difficulties and their association with depression and other factors among gay men attending high-HIV-caseload general practices in Australia. The Journal of Sexual Medicine 2009;6(5):1378-1385.

5. Körner H, Newman C, Mao L, et al. 'It's really a myriad of different signals, not just the textbook': The complexities of diagnosing depression in gay men in general practice. Mental Health in Family Medicine. 2008;5(3):167-175.

6. Newman CE, Kippax SC, Mao L, et al. Features of the management of depression in gay men and men with HIV from the perspective of Australian general practitioners. Family Practice. 2009;26(1):27-33.

7. Newman CE, Kippax SC, Mao L, et al. GPs understanding of how depression affects gay and HIV positive men. Australian Family Physician. August 2008;37(8):678-680.

8. Newman CE, Kippax SC, Mao L, et al. Roles ascribed to general practitioners by gay men with depression Australian Family Physician. 2010;39(9):667-671, 674.

9. Newman CE, Mao L, Canavan PG, et al. HIV generations? Generational discourse in interviews with Australian general practitioners and their HIV positive gay male patients. Social Science & Medicine. 2010;70(11):1721- 1727.

Competing interests:   None declared

Thank you for your endorsement of our recommendation that evidence- based guidelines for the care of LGB people should be produced specifically for primary care settings. We would add to your list of suitable agencies to develop such guidelines each of the Colleges of General Practice in the countries of interest, aside from the Irish College, whose guidelines were included in our review.

We agree with your criticism that our review did not specifically include same-sex attracted or gender questioning adolescents. This is a very important group with significant health disparities as you point out, and we could have extended our review criteria to be more inclusive. However, several of the reviewed guidelines did include reference to this sub-population, and the collated guidelines readily apply to the primary care of this group. Also, the primary care of gender questioning, transgender and intersex people deserves a completely separate systematic review, because, while there is overlap, many of the issues are quite distinct from those of LGB people.

Competing interests:   None declared

The findings reported by McNair and Hegarty regarding a paucity of primary care clinical guidelines for LGBT patients are not surprising. LGBT health issues are difficult to study for a multitude of reasons including participant mistrust of the health care setting and health care research, insufficient LGBT research infrastructure and funding opportunities, a small but growing number of LGBT health and public health researchers, and a lack inclusion of markers for sexual orientation, gender identity and gender expression in national and state health surveys. Sampling methods often are more limited and often have limitations to generalizability.

Although the 2010 National Survey of Sexual Health and Behavior reported that 7 to 8% of the US adult population is Lesbian, Gay or Bisexual, and that a greater number have had same sex experiences, little public health or population based research is available in the literature (1). In a 2008 study, Boehmer reported that LGBT issues were addressed by 0.1% of all Medline articles (2). Of these over 60% of the articles were disease-specific, and the majority omitted reference to race and/or ethnicity. Research unrelated to sexually transmitted diseases addressed lesbians and gay men with similar frequency, whereas bisexual persons were less frequently considered, and the least amount of research focused on transgender individuals.

One criticism of the manuscript by McNair and Hegarty is that the authors omit any reference to the care of non-gender conforming youth, questioning youth, and Lesbian/Gay/Bisexual self-identified youth. Pediatric aged patients were not included in the inclusion criteria nor the search items listed by the authors. In the United States, family physicians, adolescent health specialists, general pediatrics and some general internists provide primary care and preventive health services for adolescents. Pediatricians and adolescent health researchers have long reported health concerns for LGBTQ youth including depression, suicide, high risk sexual behavior, running away, sexually transmitted infections including HIV infection and substance abuse (3, 4). Although existing research has not yet culminated in the development of evidence-based pediatric patient care guidelines, there has been research regarding health outcomes of children with same sex parents (5, 6), family rejection as a risk for negative health outcomes (7), and homelessness (8). In recent years, larger population based surveys have begun to more systematically include some measures of sexual orientation as part of the survey tool. Surveys such as the Growing Up Today Study (GUTS), a longitudinal study of the children of the Nurses’ Health Study II, as well as the Youth Risk Behavior Surveys (YRBS) provide opportunities for public health researchers in adolescent health to better understand and develop evidence based care guidelines for this patient population. Although these studies often utilized a monolithic definition for sexual orientation (either self-identification, behavior, attraction, or experience alone) and likely underestimate the prevalence of same-sex identities and behaviors, they provide a starting point for ongoing investigations.

I fully support the authors’ assertion that future LGBT guidelines should be specifically and rigorously developed for primary care. Professional organizations such as the American College of Physicians (ACP), the American Academy of Pediatrics (AAP), the Society of Adolescent Health and Medicine (SAHM), the American Academy of Family Physicians (AAFP), the American Public Health Association (APHA) and the American Medical Association (AMA) as well as LGBT-focused organizations such as the Gay Lesbian Medical Association (GLMA), The Center for Population Research in LGBT Health at the Fenway Institute, and the National Coalition on LGBT Health can promote the policy initiatives necessary to create and maintain the milieu in which LGBT-focused research can thrive.

References:

1. Reece M, Herbenick D, Schick V, Sanders SA, Dodge B, Fortenberry JD. Background and Considerations on the National Survey of Sexual Health and Behavior (NSSHB) from the Investigators. J Sex Med 2010; 7(suppl 5):243-245. DOI: 10.1111/j1743-6109.2010.02038.x

2. Boehmer U. Twenty Years of Public Health Research: Inclusion of Lesbian, Gay, Bisexual and Transgender Populations. Am J Public Health. 2002;92:1125–1130

3. Remafedi, G, Adolescent Homosexuality: Issues for Pediatricians, Clin Pediatr 1985; 24: 481-485

4. Garofalo R , Wolf RC, Kessel S, Palfrey J, DuRant RH. The Association Between Health Risk Behaviors and Sexual Orientation Among a School-based Sample of Adolescents. Pediatrics, May 1998; 101: 895 - 902. 5. Pawekski JG, Perrin EC, Foy JM, Allen CE, Crawford JE, Del Monte M, Kaufman M, Klein JD, Smith K, Springer S, Tanner, JL, Vickers, DL. The Effects of Marriage, Civil Union, and Domestic Partner Laws on Health and Well-being of Children. Pediatrics Volume 118, Number 1, July 2006. 349- 64

6. Gatrell N, Bos H. US Longitudinal Lesbian Family Study. Pediatrics. 2010 Jul;126(1):28-36. Epub 2010 Jun 7. DOI:10.1542/peds.2009- 3153

7. Ryan C, Huebner D, Diaz RM, Sanchez J. Family Rejection as a Predictor of Negative Health Outcomes in White and Latino Lesbian, Gay, and Bisexual Young Adults. Pediatrics 2009; 123; 346-352

8. Kruks G. Gay and Lesbian Homeless/Street Youth: Special Issues and Concerns. Journal of Adolescent Health 1991; 12:515-518

Competing interests:   None declared