LGBT patients search for healing
A ll Jessica wanted was a doctor who would treat her like everyone else. A doctor who was comfortable with her self-identification as queer - a term sometimes used as an umbrella for any variation of lesbian, gay, bisexual, or transgender orientation.
But it wasn’t until she moved to Boston, in her 30s, that she was ready to even try to look for one. Before that, “the only office I went to was the dentist,’’ said the Jamaica Plain resident, who asked to be identified only by her first name to protect her privacy.
Despite overall strides in the attitudes toward people who identify as lesbian, gay, bisexual, or transgender many argue that the medical community has lagged behind. In 2009, fewer than a quarter of 1 percent - .21 percent - of publications related to human health included an LGBT-related keyword, as indexed in PubMed, an online library of research abstracts run by the National Institutes of Health.
Yet researchers say that LGBT people are more likely to experience a variety of health problems - from mental illness to drug abuse to sexually transmitted and other diseases - than their straight counterparts. The reason is largely that they don’t seek health care for fear of being stigmatized in the doctor’s office.
“These are not LGBT health issues,’’ said Dr. Alex Gonzalez, medical director at Fenway Health, where Jessica is a patient. “They become LGBT health disparities because LGBT people have had an alienating experience with health care in the past.’’
But providers at Fenway, which has specialized in LGBT-competent care since the time when homosexuality was still officially considered a mental disorder, and elsewhere in Massachusetts say many of these heath disparities could be eradicated if doctors just asked better questions in a better way.
Starting with asking for the patient’s name.
“How do you like to be called?’’ is one example that comes to Dr. Carole Allen’s mind when she thinks of ways to make a patient who may be transgender more comfortable. For Allen, who is chief of pediatrics at Harvard Vanguard Medical Associates, such approaches are key for adolescents who may be questioning their sexual orientation or gender.
“As soon as you say to a patient, ‘Do you have a girlfriend?’ You’ve automatically cut off that conversation,’’ Allen said. So about 10 years ago, Allen came up with asking, “Have you noticed any attraction to boys or girls or both?’’
And while Allen wasn’t sure how teens would react, she found that most weren’t at all offended. “Some kids will laugh. But I’ve had some kids say, ‘I haven’t decided’ or ‘I don’t know.’ ’’ Some of those kids hadn’t talked about their sexuality with anyone until Allen asked.
Once patients confide in her, Allen can help connect them to whatever services they need and talk to them about relevant safe-sex practices.
But a competent doctor isn’t always enough. Patients can be discouraged from seeking care before they’ve even gotten to the waiting room.
“There’s a real shift in our culture now from overt homophobia to more covert homophobia,’’ said Tina Gelsomino, an administrator at Brigham and Women’s Hospital who co-chairs a group that represents LGBT staff. “It’s not necessarily what people say, it’s sort of what they don’t say.’’
Take patient intake forms, for instance. There’s rarely space for patients to indicate their sexual orientation or whether they are transgender. In some cases, Jessica has identified herself as female on a form and written “having sex with women.’’
Dr. Kevin Ard, who co-chairs the Brigham group with Gelsomino, offered another example: A receptionist asks an incoming patient if he is married or single, and the man says “I’m partnered.’’ The receptionist responds, “Oh, so you’re single?’’
That kind of interaction can prevent someone from seeking out care again - or at least from divulging their sexual orientation or gender identity to a doctor, said Ard.
The Brigham recently launched a campaign called “Be an Ally,’’ encouraging all staff members to wear a rainbow sticker on their identification badge to show support for LGBT staff and patients. So far, Gelsomino and Ard say they have given away hundreds of stickers.
“As a gay provider, it’s actually really great for me to see all these people wearing it around the hospital,’’ said Dr. Mitchell Lund, who began his residency at the hospital in June 2010. “Something as simple as this . . . is a powerful statement.’’
Lund has made it a point to ask his patients open-ended questions about their sexuality in his primary care practice since he started as a resident. He’ll casually mention that he has patients who are attracted to men, women, or both - or patients who may look like a man, but say they feel more like a woman. Then he’ll say, “Where do you fall?’’
Even for Lund, the questions weren’t easy to ask at first. “I’m a gay man practicing medicine and it’s hard for me to talk about it,’’ he said. But he found most patients answer his questions as though they were answering any routine query: “Patients don’t think it’s as awkward as you do.’’
Many doctors don’t learn to ask such questions during residency or medical school. In a recent study Lund coauthored in the Journal of the American Medical Association, a third of medical schools surveyed said they offered no instruction on LGBT-related content during students’ clinical years.
“You can’t learn this stuff through books or a written exam,’’ said Dr. Scott Leibowitz, a psychiatrist at Children’s Hospital Boston. “The only way to foment sexual- and gender-competent care would be to have treatment programs that exist that bring in the patients.’’
One day a week, Leibowitz coordinates a pilot program at Children’s for patients who are transgender or what he calls “gender variant.’’ When children come into his office asking whether they might be transgender or gay, he has the training to help them sort out those questions.
More than 20 percent of some 7,000 transgender subjects questioned reported having to teach their doctor about transgender care, according to survey results published in October 2010 by the National Center for Transgender Equality and the National Gay and Lesbian Task Force.
“Imagine how you would feel if you have an illness . . . and you’re going to somebody [for health care] where you have to explain it to them,’’ said Joanne Herman, a Fenway patient who had a sex-change operation in 2003. “Why bother going to an expert if you are one?’’
At Fenway, says Herman, she feels comfortable getting routine care. Her previous doctor at a different hospital was well-intentioned, but could never get through a gynecological exam without mentioning that Herman doesn’t have a cervix. Now, she said, “my primary care doctor does my GYN exam, and it’s done without commentary.’’
Jessica has been a patient at Fenway since last year. Just walking into Fenway, she says, is a vastly different experience than walking into most health care settings because of a few well-placed “visual cues.’’
The center’s non-discrimination policy for patients is made especially visible in the lobby. Fliers seeking LGBT study participants are prominent, as are notices about support groups for people who are HIV-positive.
“We’re able to get people in the door,’’ Gonzalez said. “And it sounds like a very easy thing to do, but so many people out there have had an alienating experience with health care in the past.’’
The kinds of questions that Fenway doctors routinely ask - about same- or opposite-sex attraction and sexual activity, for instance - should be asked of every patient, whether or not that patient identifies as LGBT, Gonzalez said.
He has found that patients will answer almost anything if he prefaces taking a medical history with: “I’m going to ask you a few questions because it’s actually going to help me figure out what I’m going to swab today.’’
Neena Satija can be reached at firstname.lastname@example.org.