Inclusive sexual healthcare for LGBT+ people

LGBT+ people often face stigma and discrimination. Although these things are linked, they are not the same thing.

Stigma is when people feel, think and talk negatively about and to LGBT+ people. It relates to people’s attitudes and views.

Discrimination is when stigmatising views result in LGBT+ people being treated unfairly. Discrimination can happen in many different circumstances, including at home, in school, at work and in healthcare. It also includes discriminatory laws, such as criminalisation.

What are your own views and attitudes on LGBT+ people? Have a think about this, and be honest. A lot of us hold stigmatising views, and that’s because they are all around us. The first step is to recognise any stigmatising views you may have, then challenge yourself to think differently.

The stigma, discrimination and criminalisation that LGBT+ people face stops many from accessing sexual health services, including HIV and STI prevention, testing, treatment and care. People may be too scared to test for HIV or to take treatment if they need it. That is why stigma, discrimination and criminalisation are major drivers of the HIV epidemic and a threat to public health.

Stigma and discrimination can cause some LGBT+ people to feel anxious or depressed and lead to a range of mental health issues. It can cause some LGBT+ people to misuse alcohol and drugs and increase the sexual risks they take, all of which makes people more likely to get HIV and STIs. Stigma and discrimination can also stop LGBT+ people from getting the mental health support they need to cope with what they are experiencing.

LGBT+ stigma and discrimination is wrong. It’s important to treat everyone with the same respect, regardless of their gender and sexuality. This is the only way to do your role in a professional, non-discriminatory and effective manner.

• Be respectful and friendly

Respect people’s dignity, treat them with kindness and compassion and ensure their privacy and confidentiality.

• Don’t make assumptions

Never assume you know what someone’s gender-identity or sexuality is just by how they look or act. And do not assume that every LGBT+ person will have the same lifestyle, experiences or issues. Take time to understand who they are as a person and what support they need from you.

• Use neutral language, until you are sure – then echo what they say

For example, in English say ‘your partner’ instead of ‘your husband/wife’. And use the gender-neutral pronoun ‘they’ until you know what pronoun the person likes to use. (Pronouns are ‘he’, ‘her’ and ‘they’ but never ‘it’.) If they use a specific term to describe themself, such as ‘male’, female’, ‘gay’ or ‘trans’, use it too. Use the name they call themselves, even if it is different from the name on their record.

• Don’t judge

Do not judge people for being who they are. Instead, try to educate yourself on the wide range of LGBT+ issues that exist, which you can do with the help of Be in the KNOW. Let them know that you are here to help, not to judge them. Your body language, facial expressions, and the tone and pitch of your voice can suggest surprise or disapproval, so try to keep these things neutral.

• Be open

If an LGBT+ person opens up to you about a sexual health issue, listen to them and take them seriously. Only ask questions that are relevant to whatever issue they have come to you with. It is not okay to ask them questions to satisfy your curiosity or to infer blame.

This may look like a lot to remember! But it is easy to do once you have some practice. And remember that you are only human – if you make a mistake, apologising can go a long way and get things back on track.

Read our Community Voices section for more on how to make HIV services friendly for gay men and transgender people.

Transitioning describes the changes that some trans and non-binary people make so they can live in a way that better reflects their gender identity.

Gender dysphoria are feelings of unease that some people get if their gender identity and their body don’t match up. This unease can also come from being treated as a certain gender by others when they do not identify this way.

Not every trans or non-binary person gets gender dysphoria. But for those who do, here are some things you can do to support them:

• Understand the facts: our sexual health page for trans, non-binary and gender diverse people is a good place to start.

• Ask them open questions to understand what they currently know and what their questions and concerns are. Do not assume that you know how they feel or their level of understanding.

• Let them know you are here to support them, you will not judge them, and that you will keep whatever they tell you confidential.

• Research trans and non-binary support groups, either in your area or online, which you can connect them with if they want to take this step. This is a good way to show them they are not alone in what they are feeling.

• Research the laws in your country on gender identity and recognition, and find out whether gender-affirming healthcare is available. But only talk to them about these things if they ask you questions about it – it is important to be led by whatever pace they want to go at.

• Try to talk to them about how they are feeling about what they are experiencing, and whether they need any mental health support. Let them know that exploring how they feel, and learning to love and accept it, can be hard. But it’s one of the best things they can do for themselves. 

• It is also a good idea to talk to them about  how to look after their sexual health if they are sexually active, including how to get pleasure from their body.

If you work in a context where LGBT+ people (and possibly even those who support them) are criminalised and you are unsure how to approach an LGBT+ person, try the following things:

• arrange to meet them somewhere discreet and private
• let them know you are not here to judge or report on them: you are here to support their health
• tell them that whatever they tell you will be kept private.

If you want to promote sexual health, the best way to do it is to help people understand their HIV prevention options, not judge their choices. This video on getting real about sex without a condom is a good one to share with gay clients and other people who have anal sex to start an open and honest conversation with them about the different HIV prevention options on offer.

HIV prevention choices have changed and expanded. The most relevant to LGBT+ people are:

• Condoms: There are two types: external condoms and internal condoms. Internal condoms can be used inside the anus during anal sex. It is also important to talk to people about lubricant, especially if they are having anal sex. Not everyone likes using condoms. This is important to consider when talking to someone. This video is useful to share to help people understand that condoms can be a pleasurable part of sex.

• PrEP: It is scientifically proven that people who know they are HIV-negative and take pre-exposure prophylaxis (PrEP) correctly and consistently cannot get HIV. However, PrEP does not prevent other STIs. Find out what PrEP options are available for LBGT+ people where you are before you start recommending them.

• PEP: Post-exposure prophylaxis (PEP) is a form of emergency treatment which people can use to stop themselves getting HIV after they have had unsafe sex.

• U=U: It is scientifically proven that people with HIV who are on effective antiretroviral treatment, with an undetectable viral load, cannot pass on HIV through sex. This is referred to as undectable=untransmittable or U=U.

There is a big link between how people feel about themselves and how they behave sexually. If someone is struggling with their mental health, they might make choices they feel uncomfortable with, like saying yes to sexual situations they don’t want to, or having sex unsafely. This is one of the reasons why it is good to offer support on mental health and wellbeing. But you will need to judge each situation on a case-by-case basis, and only start this conversation if it seems appropriate.

A good way to begin this conversation is to simply ask how they are. But mental health can be hard to talk about, or even recognise, so don't pressure them to speak if they don’t want to.  

The advice you give them will depend on what they tell you, but here are some general things that can be useful to say.

Looking after their physical health: If people look after their physical health, it can help their mental health too. This is about taking some exercise, trying to eat and sleep well, and avoiding drinking too much alcohol or taking too many recreational drugs.

Joining a support group, or talking to other LGBT+ people: Suggest that it might help them to talk to other LGBT+ people who may have experienced similar things. You could try connecting them with an LGBT+ support group, online forum, helpline or an LGBT+ peer supporter. To find out what is available, search online for ‘LGBT+ support’ in your area.

Self-kindness: Let them know most people feel down or worried at some point. But tell them that they don’t have to put up with feeling bad all the time, and they have a right to be happy. The first step is trying to accept and love who they are and being kind to themselves, rather than feeling guilty or bad. Let them know there is no reason to feel ashamed simply for being who they are.

Here are some tips and discussion starters on mental health to share with all young people, including LGBT+ people. And on these pages, you can find tips on mental health specifically for gay men and trans people.