Andrew Gilliver and Clare Marshall explain why dental professionals need to be LGBT aware.
Most of us like to think that as professionals we are focused on the needs of our patients, but do we actually know enough about what our patients need from us?
Many people are anxious about a trip to the dentist. For lesbian, gay, bisexual and trans (LGBT) people there are some very real concerns.
Results from the Government's National LGBT Survey (2018) overwhelmingly demonstrate the significant barriers faced by LGBT people in the UK today.1 The survey confirms that growing up LGBT in an intolerant society, experiencing prejudice and rejection, can exacerbate health inequalities and have a negative impact on health outcomes compared to the general population.
Evidence suggests that discriminatory attitudes towards LGBT people are still commonplace. A 2019 survey revealed that 1 in 5 people said being LGBT was 'immoral or against their beliefs' and 1 in 10 people claimed that being LGBT could be 'cured'.2
What can dental professionals do to support their LGBT patients?
Seven ways to make your dental practice LGBT inclusive
All quotes are from LGBT patients and LGBT inclusive dental services.
1. Reach out to the LGBT Community
'I appreciated the opportunity of [having] a dental check in a safe and non-judgemental setting, having previously been subjected to a disappointing experience on visiting my last dentist'
Visibility is a key component to creating a safe space and helping patients to feel recognised. One example would be to display posters showing diverse communities or local LGBT organisations. Familiarising yourself with local LGBT services in your area can help you understand the challenges faced by your LGBT patients. Signposting to a mix of mainstream and LGBT specific services (eg substance use) can help your patients to feel confident in your services.
*Training is available for practices that want to learn more about how to support their LGBT patients.
2. Utilise monitoring opportunities
'Since we have become more pro-active about sexual orientation and trans status monitoring, we have definitely witnessed a marked increase in the number of our patients who are willing to share this information with us.'
Patient forms and medical histories with no representation of diverse sexual orientation or gender are a sign that LGBT people are not acknowledged. It can help your business to show that you understand the importance of representation. It also demonstrates that you are following legal guidance in recognising your patients' protected characteristics. Collecting a range of demographic information can help you to avoid assumptions and initiate conversations around pronouns or wider health issues eg diagnosing HPV in the mouth.
3. Talk openly about the connection between oral health and sexual health
'In my experience of attending dental surgeries, I have never noticed any displays of leaflets on sexual health or any clues it is ok to ask about sexual health.'
Dental professionals are well placed to give patients advice on sexual health, based on their oral health. HIV, HPV and syphilis are all conditions that can be diagnosed in the mouth. However, patients may not be aware of this and dentists may not feel confident in initiating discussions on this topic. Proactively engaging in conversations with patients can help them to be more aware and informed about their oral health and the effects of STIs on the oral cavity. It also indicates that they are in a safe environment where they can discuss any concerns without fear of judgement.
4. Share your knowledge with your LGBT patients
'Your role is to bring up anything that you can see that affects oral health. You have to give people the option to be honest.'
As a dental professional, identifying, treating and signposting are crucial to our roles. LGBT people have higher rates of smoking, alcohol consumption and substance use than the general population. Talking to your patients about the effect of substances on their oral health can help them to make informed decisions. For example, explaining that party drugs can lead to the gradual destruction of the tooth and damage to the gums. Your patients will understand that you are supporting them and providing the care that they need, even if they are not initially aware that they need it.
5. Help reduce HIV stigma
'I really want to find a dentist that can help me, but I need to feel sure that they will not judge me either for my past history, my HIV status or how I've handled my healthcare in the past.'
Many people worry about discussing HIV with any health professional. Some will have been refused appropriate care and services and be anxious to know if their dentist is informed and supportive. HIV is easily treated and a patient on long-term HIV medication is doing their best to look after their health. HIV positive patients, whatever their identity, have the same right to medical attention as everyone else. It is important to understand the complications that HIV and HIV medications can cause in relation to oral health. Knowing where to refer patients for further support is vital for your reputation as a trusted health professional.
6. Understand trans people's experiences
'I learned how to engage with my trans patients by ensuring that I use the correct gender pronouns. I gained so much trust from one particular patient that he now doesn't want to see any other dentist.'
Trans people face a range of challenges when accessing mainstream services, and as a result may choose to avoid them altogether. Eighty percent of trans people experience anxiety before accessing treatment due to fears of insensitivity, misgendering and discrimination.3 By better understanding your trans patients, you can help to signpost them to appropriate, relevant and specific sources of support for their health and wellbeing.
7. Acknowledge LGBT parents
'As a paediatric dentist, I walked a 4-year-old patient back to the waiting room. I asked, "Is your mummy or daddy here?" The child, who had two mummies, burst into tears.'
A third of the public believe that heterosexual couples make better parents than same-sex couples.4 As a result, LGBT families continue to face discrimination from health care, nursery and school workers and from extended families. Using gender-neutral language eg parent or carer, can help to avoid assumptions about the gender of parents and their partners. We all make mistakes and assumptions. The important thing is to acknowledge them, apologise, learn and move on.
Some LGBT oral health risks
Smoking rates are significantly higher among the LGBT population. 18.8% of heterosexual people smoke. This compares to 27.9% of lesbian women, 30.5% of bisexual women, 23.2% of gay men and 26.1% of bisexual men.5
A 2012 study of trans people in the UK found that 19% were current smokers.6 However, a lack of routine and standardised monitoring around trans status means that there is a dearth of accurate information about smoking rates among the UK trans population.
Reasons for this are varied and complex but a large proportion of research indicates minority stress as a key factor. One survey found that minority stress was the most commonly cited trigger among LGBT people.7
A 2018 a survey by Stonewall found that 1 in 6 LGBT people drank alcohol almost every day in the preceding 12 months. By comparison, 1 in 10 adults in the general population drink alcohol on five or more days in the week.8
LGBT Foundation's Part of the Picture research revealed that binge drinking is around twice as common in gay and bisexual men compared to men in general, and almost twice as common in lesbian and bisexual women compared to women in general.9
Drug use is higher in LGBT communities10 and research shows that LGBT people are often early adopters of certain new drug trends such as 'club drugs' and psychoactive substances.11
The 2013/14 Crime Survey for England and Wales found that 28.4% of LGB adults had taken drugs in the last year. Broken down by gender, this report showed a considerable difference in the drug use between men and women with 33% of gay and bisexual men taking drugs compared to 22.9% of lesbian and bisexual women. By comparison, only 8.1% of heterosexual adults had used drugs in the last year.12
The 2012 Trans Mental Health Study found that 24% of participants had used drugs in the 12 months preceding the survey.6
Reducing the rate of new HIV diagnoses remains high on the public policy agenda. In 2017, there were 4,363 new diagnoses of HIV in the UK. Fifty-three percent of these were among gay, bisexual, and other men who have sex with men (MSM).13
Globally, trans women are estimated to be 49 times more likely to be living with HIV compared to the general population.14
Despite MSM making up over half of new HIV diagnoses in 2017, between 2012 and 2018, the overall number of cases among gay and bisexual men decreased by 71%.13 This demonstrates that promotion of regular testing and access to preventative medication such as PrEP (where available) is having a positive effect. Sadly, stigma around HIV is still prevalent with one report noting that someone living with HIV had only been offered appointments at the end of the day because the dentist believed they would pose a risk to other patients.15
As has been mentioned, sexual health is an important part of our overall health and wellbeing.
In recent years, gay, bisexual men and MSM have seen sizable increases in diagnoses of STIs particularly chlamydia, syphilis, and gonorrhoea.16In addition, less than half of lesbian and bisexual women have had STI testing with many believing they were not at risk.17
Stigma attached to discussing sex, gender and relationships means it can be difficult to access good quality, sex-positive advice, especially for young people.
Frameworks to help make your practice LGBT+ inclusive
Recent years have shown an increased awareness of the gaps in service provision for LGBT people. Legislation is constantly evolving to ensure people with protected characteristics are included within NHS protocols and receive equitable healthcare. There is still some way to go but the following guidance and legislation exists to help you support your patients in the best way possible.
*Reach out to the LGBT Community
Established in 1975, LGBT Foundation are a nationally significant charity that exists to support the needs of the diverse range of people who identify as lesbian, gay, bisexual and trans. Their Pride in Practice programme improves healthcare for LGBT communities by embedding good practice within primary care services. If you have further questions about supporting LGBT patients, contact firstname.lastname@example.org.
Training is available for dental teams who want to find out more: https://lgbt.foundation/piptrainingacademy.
Government Equalities Office. National LGBT Survey. 2018. Available at: https://www.gov.uk/government/publications/national-lgbt-survey-summary-report (accessed June 2020).
Stray M. The Hate Crime Report 2019. Galop, 2019. Available at: http://www.galop.org.uk/hate-crime-report-2019/ (accessed June 2020).
LGBT Foundation. Transforming outcomes. 2017. Available at: https://lgbt.foundation/transformingoutcomes (accessed June 2020).
Fostering and Adoption Action. Charity: Hostility to Gay Adoption 'Damaging'. 2011. Available at: https://www.govtiq.com/FostAndAdopt1V1.pdf (accessed June 2020).
ONS. The Odds of Smoking by Sexual Orientation in England, 2016. 2018. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthinequalities/adhocs/009373theoddsofsmoking bysexualorientationinengland2016 (accessed June 2020).
McNeil J, Bailey L, Ellis S, Morton J, Regan M. Trans Mental Health Study 2012. Scottish Transgender Alliance. Available at: https://www.gires.org.uk/wp-content/uploads/2014/08/trans_mh_study.pdf (accessed June 2020).
Heyworth B, Roberts L, Mackereth P. Proud2BSmokefree. 2017. Available at: https://issuu.com/lgbtcancersupportalliance/docs/proud2bsmokefree_final_pdf_for_onli (accessed June 2020).
Bachmann C, Gooch B. LGBT in Britain. Health Report. 2018. Stonewall and YouGov. Available at: https://www.stonewall.org.uk/system/files/lgbt_in_britain_health.pdf (accessed June 2020).
Buffin J, Roy A, Williams H, Winter A. Part of the Picture: Lesbian, gay and bisexual people's alcohol and drug use in England (2009-2011). LGBT Foundation, 2011. Available at: http://clok.uclan.ac.uk/9598/1/POTP%204th%20Year%20Report.pdf (accessed June 2020).
Abdulrahim D, Whiteley C, Moncrieff M, Bowden-Jones O. Club Drug Use among Lesbian, Gay, Bisexual and Trans (LGBT) People. Novel Psychoactive Treatment UK Network (NEPTUNE), 2016. Available at: http://neptune-clinical-guidance.co.uk/wp-content/uploads/2016/02/neptune-club-drug-use-among-lgbt-people.pdf (accessed June 2020).
Measham F, Wood D, Dargan P, Moore K. The rise in legal highs: prevalence and patterns in the use of illegal drugs and first-and secondgeneration 'legal highs' in South London gay dance clubs. 2011. Available at: https://www.tandfonline.com/doi/abs/10.3109/14659891.2011.594704 (accessed June 2020).
The Home Office. National Statistics Drug misuse: Findings from the 2013/14 Crime Survey for England and Wales. 2014. Available at: https://www.gov.uk/government/publications/drug-misuse-findings-from-the-2013-to-2014-csew/drug-misuse-findings-from-the-201314-crime-survey-for-england-and-wales (accessed June 2020).
Public Health England. Progress towards ending the HIV epidemic in the United Kingdom: 2018 report. 2018. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/821273/Progress_towards_ending_the_HIV_epidemic_in_the_UK.pdf (accessed June 2020).
Public Health England. HIV in the United Kingdom: Towards Zero HIV transmissions by 2030. 2019. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/858559/HIV_in_the_UK_2019_towards_zero_HIV_transmissions_by_2030.pdf (accessed June 2020).
LGBT Foundation. Primary Care Survey Report. 2017. Available at: https://lgbt.foundation/evidence/primary-care-survey-report/20 (accessed June 2020).
Public Health England. Sexually transmitted infections and chlamydia screening in England: 2017. 2018. Available at: https://www.gov.uk/government/statistics/sexually-transmitted-infections-stis-annual-data-tables (accessed June 2020).
LGBT Foundation. 2018. National Sexual Wellbeing Survey 2018: Women Who Have Sex with Women. Hidden Figures - LGBT Inequalities in the UK. 2020. Available at: https://s3-eu-west-1.amazonaws.com/lgbt-website-media/Files/b9398153-0cca-40ea-abeb-f7d7c54d43af/Hidden%2520Figures%2520FULL%2520 REPORT%2520Web%2520Version %2520Smaller.pdf (accessed June 2020).
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Gilliver, A., Marshall, C. Having pride in your practice. BDJ Team 7, 10–13 (2020). https://doi.org/10.1038/s41407-020-0369-y