Unbelievably, this is what the senior surgeon “growled” at Dr. Pauline Chen and her cohort during surgery training, according to her article in The New York Times entitled “Does Medicine Discourage Gay Doctors?” In other words, the surgeon was equating the word “homosexual” with “insufficient.” This does not make much sense to me and is, quite frankly, poor usage of the word; however, he apparently had no qualms about throwing the word around in such a haphazard manner. Another problem was this: one of those surgeons-in-training with Dr. Chen was homosexual. Imagine how uncomfortable the rest of the rotation must have felt for him — suddenly having to become even more self-aware about his speech, walk, gesticulations and how much time he spent talking with male friends versus those who were female.
One physician, Dr. Mark Schuster, recalls his experience as a medical student at Harvard in the journal American Pediatrics. He recounts the time a powerful physician in his specialty volunteered to write him a great recommendation letter for his pediatrics residency program. Dr. Schuster felt the need to be totally honest with his soon-to-be top letter writer because he didn’t want him to find out from someone else that he was, in fact, gay. So, Dr. Schuster decided to tell his mentor one day at the conclusion of a conversation. This man, who had previously volunteered himself to be Dr. Schuster’s top letter writer, reacted with a long silence. When he finally did speak, he instructed Dr. Schuster to not tell anyone else at the hospital. Then, while Dr. Schuster was finalizing his application packet before the deadline, his mentor informed him that he would no longer write a letter of support for his residency application.
Unfortunately, this attitude may not be uncommon within the medical profession. According to the Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients published by the Gay and Lesbian Medical Association (GLMA), a survey of nursing students uncovered the following: eight to 12 percent of them “despised” lesbian, gay, and bisexual people (LGB), five to 12 percent thought them to be “disgusting,” and 40 to 43 percent thought LGBs should keep a lid on their sexual identity, remaining private about it.
An article from US News & World Report published in 2011 entitled “Medical Schools Admit Neglecting Gay Applicants, Health Issues” discussed the issue that “many medical schools acknowledge they aren’t addressing LGBT health sufficiently.” Further, Stanford University’s LGBT Medical Education Research Group published an article in the Journal of the American Medical Association that discovered through a survey of US and Canadian medical school deans, 33 percent of the responding schools provided no LGBT-related instruction during the students’ clinical years and 6.8 percent provided no such content during the preclinical years.
But I must ask: is there a legitimate need for LGBTQ-focused health care initiatives? LGBTQ stands for lesbian, gay, bisexual, transgender and queer. I am willing to bet that some of you currently reading this article are wondering if the term “queer” is politically correct. The very fact that some are wondering this answers my question with a big yes! If this term, merely presented here in literature, is uncomfortable or raises questions, how would you react to someone sitting in front of you who self-identifies as queer? Would you know the differences between being gay, lesbian or queer? Would you know what having a queer mindset entails? For the record, the term “queer” is embraced by the younger gay community, but may still be shunned by older LGBT people. More of these patients are coming out in need of excellent care, and I believe the medical community needs more training in order to afford adequate health care to the LGBTQ patient. Therefore, I advocate that a minimum level of LGBTQ-focused content should be taught at all medical schools.
I want to make it clear that this article’s purpose is neither to condemn nor actively support the LGBTQ community. How I or any other medical professional personally feels about matters concerning sexual orientation is completely irrelevant in regards to providing comprehensive health care. What is relevant, however, is that health care providers treat each patient with the same level of respect, dignity and care. Therefore, based upon this ideal, the main purposes of this brief article are to shine light upon the growing niche of LGBTQ-focused medicine, to bring awareness to some unique issues within it, and to explore why the need for LGBTQ-focused medicine really exists. In an age where cultural competence is key to providing adequate and comprehensive health care, we must not neglect this fast growing subculture. But, to accomplish this goal, we will need to begin at the educational level.
Lately, LGBT issues have enjoyed unprecedented attention, largely due to the uprising in gay marriage political issues. LGBTQ-focused medicine is a growing medical niche that has slowly gained attention over the last few years as well, albeit minimally. Medical schools are beginning to respond to this call, reflecting the changing dynamics and increased organization of the LGBTQ population. With new milestones being achieved in society, medical schools are trying to achieve their own. For instance, the Yale School of Medicine launched a recruitment initiative targeting the LGBTQ community. These changes are partly in response to the 2007 survey released by the Association of American Medical Colleges (AAMC) which showed one-fifth of respondents “knew of mistreatment” to LGBT medical students. The AAMC reported that, “LGBT experts and advocates are working to change policies at medical schools, in the health care system, and in society at large.” Therefore, LGBTQ-focused medicine should not only address the issue of caring for the LGBTQ patient, but also of creating an environment that fosters and appreciates a rich diversity of workers, including the LGBTQ health care provider. Health care providers in training should be able to complete their education in an environment that minimizes the stressors of feeling uncomfortable, embarrassed or discriminated against because of their sexual orientation or lifestyle — exactly the opposite of what Dr. Schuster endured. In facilitating this type of environment, we remove much of the homophobia that has plagued medicine for years and afford a more inviting and comfortable environment for the LGBTQ patient.
Obviously, in order for a culturally-specific medical need to truly exist, a culture must have distinguishing characteristics in it that are unique. So, the first question becomes, “Does the LGBTQ community qualify as a culture?” If so, then “Does this culture have unique aspects and/or disparities?” According to the AAMC, “culture” is the integrated “patterns of human behavior … of racial, ethnic, social, or religious groups.” The LGBTQ community certainly fits this definition. So, does the LGBTQ “culture,” consisting of the LGBTQ social group, have distinctive or unique aspects or disparities? According to a 2011 Institute of Medicine report, “LGBT individuals experience unique health disparities.” Furthermore, it also states that “Lesbian, gay, bisexual, and transgender individuals have unique health experiences and needs.” In short, this warrants that the LGBTQ community does, in fact, have culturally-specific medical needs.
So, what are some of these unique needs or issues? Largely resulting from the stigmas of society, LGBT populations experience significantly higher rates of suicide attempts, depression, homelessness, and drug abuse. Even within the LGBT culture (which constitutes approximately 3.4 percent of Americans according to recent 2012 Gallup poll results), distinctive health trends emerge with further division. For example, gay and bisexual men have significantly higher HIV rates, lesbian and bisexual women experience higher rates of obesity, and transgender people experience high rates of victimization and mental health disorders. Furthermore, transgender individuals are less likely to have health insurance than heterosexual or LGB individuals.
The aforementioned Dr. Schuster now works at Harvard as a medical professor and is Chief of General Pediatrics at Boston Children’s Hospital. According to Dr. Chen’s article, “The medical school and hospital where he was once encouraged to remain in the closet has now embraced him, his spouse and his children.” Dr. Schuster rose above the discrimination; however, many LGBTQ persons do not. They do not have the support they need. Knowledge of these situations, coupled with the existing culturally-specific health issues, should be alarming enough to lend credence to the big yes! that I spoke of earlier. Increasing LGBTQ-focused initiatives will educate medical professionals, thus decreasing the haphazard and wrongful usage of words like “homosexual” or “gay,” which should not be used pejoratively in the professional setting, anyway. Furthermore, more resources and support groups will be more likely to develop so that future Dr. Schusters will not have to go through their training feeling alienated, thereby creating a less stressful environment for LGBTQ health care workers as well as patients.
It is important for health care providers to be knowledgeable about the LGBTQ resources in existence for their patients. Increasing LGBTQ-focused medicine will help fill this gap in education that currently exists, as is evident by the Stanford University study referenced earlier. For example, the It Gets Better Project has been an excellent resource for many young LGBTQ people who have considered suicide as a way out. It has curbed many of them from completing the act, per testimonies online. However, this is but one resource for the many unique needs existing within this culture, and many health care providers may not even be aware of this widely successful project. By including LGBTQ-related content in our medical education, health care providers will be able to create more appropriate assessments and include supportive resources like the It Gets Better Project into their individualized planning for the LGBTQ patient.
Religious beliefs, personal feelings or other reasons may occasionally cloud some health care providers’ abilities to be unbiased towards delivering quality health care to the LGBTQ patient. I know, as a minority, that I can tell whenever a health care provider is not being sincere. I begin wondering if I am reading too much into the situation, if it is a race issue, if they have a problem with my interracial marriage, and so forth. This is an uncomfortable situation for any patient to experience. I would conjecture that this is part of the reason a recent study published in JAMA Internal Medicine revealed that most minorities seek minority physicians. According to that study, non-white physicians took care of 53.5 percent of minority and 70.4 percent of non-English speaking patients. From my personal interviews, I have noticed a similar trend amongst LGBTQ patients. Is it because they feel that they can be more comfortable with providers who are either members of the same culture or at least sympathetic to their unique issues? It is my belief that if physicians were taught a standardized minimum level of cultural competency, it would greatly improve patient outcomes and lessen this preference that exists amongst minority and LGBTQ patients.
With greater communication and knowledge about pertinent cultural issues and the resources that exist, health care providers who feel particularly passionate will inevitably arise. Several of these providers already exist and are happily registered with the GLMA database. Thanks to groups that promote LGBTQ-centered care (like the GLMA), the LGBTQ patient now has the ability to find a health care provider they can trust.
We see that society as a whole has made strides in tackling LGBTQ issues. Medical schools are now starting to make their own strides in a concerted effort to mitigate their admitted previous neglect of the LGBTQ population. Therefore, it is good for medical students of today to familiarize themselves with this growing medical niche. The medical student of today must familiarize herself with the unique issues that exist within the LGBTQ culture. This then brings us to the final issue with which this article is concerned: is there really a need for LGBTQ-focused medicine? I believe the answer is definitely yes.
One of our main goals as health care providers is to first do no harm. If we know a need like this exists, but do nothing about it, are we not guilty of offending this maxim? If a little education will curb the disparities of a culture, then should we not embrace these minor changes in our curriculum? To quote GLMA, “Today, there is still considerable ignorance about LGBT health issues, with many assuming that LGBT health involves only HIV/AIDS.” Hopefully, this article and others like it will be a starting point for changing that view.
On the Fringes is devoted to filling the missing pieces of medical school and the art of medicine, topics of discussion in medical education that are often overlooked, under-discussed, or brand new.