March 2001 • Volume 7 • Number 3
Being gay can be anything but
Know your patients -- and know the issues
BY CINDY McCANSE
It's an unfortunate reality: Segments of the American population continue to fall through cracks in the U.S. health care system.
Judith Chamberlain, M.D., encourages patients in her Brunswick, Maine, family practice to speak openly about their sexual orientation. Having that knowledge, she says, enables her to better meet their medical needs.Lack of insurance coverage, geographically limited access to health services, cultural or language barriers -- all play a role.
Yet there's another obstacle too often encountered by hundreds of thousands of people every day -- the stigma of being gay, lesbian, bisexual or transgender.
Create an open, caring atmosphere
George Gay, M.D., of Cambridge, Wis., is a self-proclaimed advocate of gay civil rights and the rights of gay patients. He's also an openly gay family physician practicing in a small rural community.
Gay says there's an interesting phenomenon associated with being a physician who's gay or lesbian. "Gay family physicians tend to be out as medical students and sometimes even into residency. Then they go back into the closet until their practice has been established for about five or six years, and then, depending on their experience, they may come back out again," he says. "Hanging out a pink triangle with your shingle isn't exactly a practice builder -- unless you live in a very unusual neighborhood.
"I came pretty close to not going into rural family practice," Gay adds, "because I used to think it would be impossible to be a family doctor and be gay. I lived 20 miles from my office for my first six years in practice. But people here have been very kind to me and my life partner of more than 20 years."
Judith Chamberlain, M.D., cares for a number of GLBT patients in her Brunswick, Maine, practice. She suggests that welcoming these patients is about knowing what not to say as well as what to say.
"I don't think it's the patients as much as it's us," says Chamberlain. "It's up to us to create an atmosphere that allows patients to talk about their sexual orientation. If you greet a woman at the door by asking 'Who's your husband?' she's not going to be willing to come out to you."
Gay also warns against making assumptions: "If the box just reads 'married/divorced/single,' you're not leaving any other options open, and your gay patients aren't going to tell you they're gay."
Know the care issues
George Gay, M.D.:
"Hanging out a pink triangle with your shingle isn't exactly a practice builder -- unless you live in a very unusual neighborhood."Just as you shouldn't make assumptions about your patients' sexual orientation, don't make faulty assumptions about their health based on that orientation. Because well-designed, population-based GLBT studies are scarce, it's hard to find reliable evidence on which to base care decisions.
"We have to be careful not to go on generalizations or assumptions predicated on false data," says Chamberlain. "Are all gay people depressed? I don't think so. Are they dealing with the stress of coming out to family and friends? Well, of course they are."
"Medical schools teach very little about cultural competency in this area," says Gay. "They may teach about ethnic issues, but not about the needs of GLBT patients."
The key is not to overlook the full range of health care services. "Don't dismiss certain types of screening because a patient is gay," Chamberlain advises. "Like screening for STDs in lesbians, because many of these women have had sex with men at some time in their life. With gay men, I think it's important that we don't presume that HIV/AIDS care is all there is. These patients need to have their cholesterol checked, they need to be told not to smoke."
Overall, says Chamberlain, "I think our job as family doctors is to bring these patients into the mainstream."
However, she says, do use your knowledge of a patient's sexual orientation to tailor the interview: "Ask about specific sexual practices because that may reveal risks you're not thinking about."
Some of the GLBT care issues the Gay and Lesbian Medical Association has on its radar screen, says FP Ronald Falcon, M.D., of Minneapolis, are hepatitis A and B vaccination of gay men; breast cancer and cervical cancer screening in lesbians; and education about the hazards of club drugs, such as ecstasy and amyl or butyl nitrate.
Expand your horizons
For more information on issues relevant to your gay, lesbian, bisexual and transgender patients, check out these resources:
Gay and Lesbian Medical Association
(415) 255-4547 -- http://www.glma.orgParents, Families and Friends of Lesbians and Gays
(202) 467-8180 -- http://www.pflag.orgAnd, unfortunately, it's important to look for red flags. Domestic violence among gay and lesbian patients presents unique problems. Think about it, says Gay. "If you're a gay man and you get beat up by your partner, where do you go? You can't go to a women's shelter; they don't want you there. And if you're a lesbian, they don't want you there, either. So you stay at home and get beat up again."
Family physicians must educate themselves about caring for these patients, says Gay. Resources are available to help FPs learn about GLBT issues (see box).
Recent efforts to expand FPs' research on GLBT populations should help, Gay says (see story at top of page 5). But he adds, "None of that is going to be real helpful until the social stigma is gone."
FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
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