NHS England’s recent recommendation that professionals ask patients their sexual orientation at every opportunity is essential to improve services for non-heterosexual patients, says Richard Ma. But Michael Dixon thinks this erosion of medical autonomy is political correctness gone mad
After decades of campaigning by lesbian, gay, bisexual, and trans (LGBT) charities such as Stonewall and the LGBT Foundation, sexual orientation became one of the nine protected characteristics written into the Equality Act 2010.1 It would seem a logical and welcome step for NHS England to include sexual orientation monitoring (SOM) in health and social care systems.2 In practice all professionals would ask patients how they define their sexuality during every encounter. Patients can, of course, refuse to answer.
However, some doctors and patients have expressed concerns about this policy, citing reasons such as intrusion or invasion of privacy, fear of causing offence, doubts about relevance, data security, and that it is a tokenistic gesture that will not make a difference. While I understand these concerns, they result in inertia; and failure to act undermines hard fought rights of LGBT patients to better healthcare.
We already fail the LGBT community by not recognising, or by making incorrect assumptions about, their needs. A Stonewall commissioned survey of nearly 7000 gay and bisexual men found that smoking, alcohol, and drug use were more prevalent in this group compared with men in general.3 More specific health needs include mental health: 6% of gay and bisexual men aged 16 to 24 have attempted to take their own life in the past year compared with less than 1% of men of the same age in general; 15% have reported self harm compared with 7% of other men.
Some people think SOM is relevant in sexual health related consultations only. This is a narrow view. Ethnicity is more than colour of your skin. Gender is more than your chromosomes. Similarly, SOM isn’t just about sex. History, culture, lifestyles, as well as struggles against discrimination, are some commonalities that unite non-heterosexual identities.
Even if SOM were just about sex, we are not even getting that right. Despite men who have sex with men being at higher risk, only a quarter and a third have been tested for sexually transmitted infections and HIV, respectively.3 A Stonewall commissioned survey of over 6000 lesbian and bisexual women reported that 15% of eligible women have not had a cervical smear compared with 7% of other women.4
Some think that treating everyone equally should be good enough. But equal treatment is not fair treatment. You would not offer vulnerable patients equal access to care like other patients—you make a special effort because of the special need. Neither can you say that you offer equitable care to LGBT patients without knowing who they are—unless you count them.
We must reflect on why we think asking about sexual orientation is “intrusive” and “insensitive”; and why some patients refuse to disclose such information. This is surprising given that a large probability sample survey of over 15 000 adults in Britain (the third National Sexual Attitudes and Lifestyles Survey) reports that 11% of women and 8% of men have had same sex sexual experience; and we have more liberal attitudes to same sex relationships than 20 years ago.5
We must create an environment where people can disclose information on their sexual orientation safely. According to a survey of more than 3000 health and social care staff, only 9% received training on needs of LGBT people; but half said that their training covered only sexual health; 16% admitted they would feel uncomfortable asking patients about their sexuality and, in contrast, they felt more comfortable asking about other protected characteristics, such as disability.6 Perhaps the health service has outdated sexual attitudes and we need to catch up.
I agree that we must make the public feel confident in how their data are used. We need to make our data secure and show that we are using them intelligently—from contextualising a person’s care and management, to service improvements.
Sexual orientation monitoring is necessary to make the health service for LGBT patients fairer. If we don’t count our LGBT patients, they don’t count.
Making doctors ask all their patients about their sexual orientation is political correctness gone mad. No one doubts that there can be great health benefits from knowing a patient’s sexuality, when offered voluntarily. There are also many occasions when, and patients for whom, it is quite appropriate for a doctor to ask. It is the “all patients” bit that is wrong.
If I start asking my 17 or 70 year olds about their sexuality, the former will think that I am weird and the latter that I have gone bonkers after being their GP for 35 years. If I then apologise and say that I am only asking because of the Equality Act and because the Care Quality Commission will be checking on me, then they might rightly wonder whether I have their best interests in mind. Sexuality, for many people, is a private thing and not an appropriate descriptor of who they are.
A patient asked about their sexual orientation has three options. To tell the truth, which is easy for many and especially, I expect, for those who support this idea. Alternatively, a patient may feel that he or she has to lie, which is bad for them, for the doctor-patient relationship, and for later consultations, when the question might be more appropriately asked and more truthfully answered. The third and quite understandable option is that the patient tells the doctor to take a running jump, in which case we are to record, in Kafkaesque terms, “The patient declined to answer.” This implies that he or she has either got something to hide or is a difficult patient.
Apparently, this is all to stop discrimination under the Equality Act, but surely the best way to avoid discrimination is by not knowing people’s sexuality in the first place. Is there good evidence that people with different sexualities are treated differently, and, much more to the point, is there any good evidence that asking them will improve things? The powers that be, NHS England, say that it won’t affect patient treatment—prompting the question of why bother?
This stupid idea symbolises the continuing erosion of medical autonomy beckoning an age when GPs become politically correct robots practising medicine by numbers. It is yet another example of overmanagement in general practice and will see yet another flood of clinicians escaping to the Antipodes or out of medicine altogether in order to elude Big Brother’s silly rules. The secretary of state for health recently warned that we are on the verge of losing the family doctor.7 Surely someone should be doing something about that rather than filling our time with more useless tasks?
In good medical practice, the patient’s own needs, wishes, choices, beliefs, culture, and perspective should come first—not the rules or diktats of any higher body. Ultimately it should be up to the judgment of each GP as to when it is appropriate or useful to ask such questions. The NHS needs to assert itself as a kind, compassionate, and intelligent service rather than a nosey parker grinding us all into cynical submission.
What about the patient? I asked my 97 year old mother what she would think if her GP asked her about her sexual orientation. “He wouldn’t,” she said confidently. “Yes, but suppose you were registering with a new doctor, and he or she asked about your sexuality?” “Well dear, I would find another doctor.”
Competing interests: We have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.

中文翻译：

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是否应该询问所有患者的性取向？

理查德·马（Richard Ma）说，英国国家医疗服务系统（NHS England）最近的建议是，专业人员应尽一切可能让患者询问他们的性取向，这对于改善非异性恋患者的服务至关重要。但是迈克尔·迪克森（Michael Dixon）认为，医疗自主权的侵蚀是政治正确性的疯狂
经过女同性恋，男同性恋，双性恋和跨性别（LGBT）慈善机构（例如斯通沃尔和LGBT基金会）的数十年竞选活动之后，性取向已成为《 2010年平等法》中写入的九个受保护特征之一。英格兰将性取向监测（SOM）纳入卫生和社会护理系统。2实际上，所有专业人员都会询问患者在每次遭遇时如何定义自己的性取向。患者当然可以拒绝回答。
但是，一些医生和患者对这种政策表示了担忧，理由是诸如入侵或入侵隐私，担心引起犯罪，对相关性的怀疑，数据安全等，并且这是一种象征性的姿态，不会有所作为。虽然我了解这些担忧，但它们却导致了惯性。未能采取行动会损害LGBT患者享有更好医疗保健的艰苦奋斗权利。
我们已经通过不承认LGBT社区或对他们的需求做出错误的假设而使LGBT社区失败。斯通沃尔委托近7000名男同性恋者和双性恋者进行的一项调查发现，与一般男性相比，该人群中吸烟，饮酒和吸毒的比例更高。3更具体的健康需求包括心理健康：6％的男同性恋者和双性恋者（16岁）过去一年中，有24至24人试图过自己的生活，而同一年龄段的男性中，这一比例通常不到1％；15％的人报告了自我伤害，而其他男人的报告为7％。
有人认为SOM仅与性健康相关的咨询有关。这是一个狭窄的视图。种族不仅仅是您肤色的颜色。性别不仅仅是您的染色体。同样，SOM不仅与性有关。历史，文化，生活方式以及反对歧视的斗争，是将非异性恋身份统一起来的一些共性。
即使SOM只是关于性，我们甚至都没有做到这一点。尽管男性与男性发生性行为的风险较高，但分别仅对四分之一和三分之一的人进行了性传播感染和艾滋病毒检测。3斯通沃尔委托对6000多名女同性恋和双性恋妇女进行的调查显示，有15％的合格女性未进行宫颈涂片检查的女性比例为7％（4）。
有些人认为，平等对待每个人应该足够好。但是，平等对待不是公平的对待。您不会像其他患者那样为弱势患者提供平等的就医机会，因为特殊需要，您需要付出特殊的努力。您也不能说您在不知道LGBT患者是谁的情况下就向他们提供了平等的护理-除非您数了他们。
我们必须反思为什么我们认为询问性取向是“侵入性的”和“不敏感的”。以及为什么有些患者拒绝透露此类信息。鉴于对英国15,000多名成年人进行的大概率抽样调查（第三次全国性态度和生活方式调查）报告说，有11％的女性和8％的男性有过相同的性经历，这令人惊讶。与20年前相比，我们对同性关系的态度更加宽松。5
我们必须创造一个环境，使人们可以安全地披露性取向方面的信息。根据对3000多名卫生和社会护理人员的调查，只有9％的人接受了有关LGBT人群需求的培训；但是一半的人说，他们的培训只涉及性健康；16％的人承认询问患者的性行为会感到不舒服，相比之下，询问其他受保护的特征（如残疾）则感到更自在。6也许卫生服务部门已经过时了性观念，我们需要跟上。
我同意，我们必须让公众对如何使用其数据充满信心。我们需要确保数据的安全性，并表明我们正在智能地使用它们-从将人员的照护和管理情境化到服务改进。
性取向监测对于使LGBT患者的医疗服务更加公平是必要的。如果我们不算我们的LGBT患者，那他们也不算。
让医生向所有患者询问他们的性取向是政治上的正确性发疯了。毫无疑问，自愿提供患者的性知识会给健康带来巨大的好处。在很多情况下，对于患者来说，对于医生来说也是很合适的。错误的是“所有患者”。
如果我开始向我的17岁或70岁的孩子询问他们的性行为，前者会认为我很奇怪，而后者会在成为他们的GP 35年后变得愚蠢。如果我然后道歉并说我只是因为《平等法》提出要求，并且因为护理质量委员会将对我进行检查，那么他们可能理所当然地想知道我是否考虑到了他们的最大利益。对许多人而言，性是私人的事情，而不是描述他们是谁的恰当描述。
询问其性取向的患者有三种选择。实话实说，对于许多人，尤其是我支持这一想法的人，这很容易。或者，当问题可能被更恰当地提出并得到更真实的回答时，患者可能会觉得自己不得不撒谎，这对他们，医患关系以及以后的咨询都是不利的。第三个也是很容易理解的选择是，患者告诉医生进行一次跳跃训练，在这种情况下，我们要用Kafkaesque的话记录“患者拒绝回答”。这意味着他或她有些藏起来或者是一个困难的病人。
显然，这一切都是为了制止《平等法》下的歧视，但是，无疑，避免歧视的最佳方法是首先不了解人们的性别。是否有充分的证据表明不同性别的人受到不同的待遇，更重要的是，是否有充分的证据表明要求他们改善情况？NHS England的权力规定它不会影响患者的治疗，从而引发了为什么要打扰的问题？
这个愚蠢的想法象征着医疗自主权的不断侵蚀，正迎接一个时代，当时全科医生已成为政治上正确的按数字进行医学操作的机器人。这是普遍管理过度的另一个例子，将看到又有大量的临床医生逃到对映体或完全没有药物，以逃避老大哥的愚蠢规定。卫生大臣最近警告说，我们快要失去家庭医生了。7肯定有人应该为此做些事情，而不是让我们的时间花在更多无用的工作上吗？
在良好的医疗习惯中，应首先考虑患者自身的需求，愿望，选择，信念，文化和观点，而不是任何上半身的规则或要求。最终，应该由每个GP来决定何时提出此类问题是适当还是有用的。NHS需要断言自己是一种友善，富有同情心和明智的服务，而不是一个爱管闲事的帕克，使我们所有人陷入愤世嫉俗的屈服之中。
那病人呢？我问我97岁的母亲，如果她的全科医生问她性取向，她会怎么想。“他不会。”她自信地说。“是的，但是假设您正在向新医生注册，而他或她询问您的性行为？” “亲爱的，我会再找一位医生。”
利益冲突：我们已经阅读并理解了BMJ的利益声明政策，没有相关利益声明。
种源和同行评审：委托；没有外部同行评审。