You can’t deliver proper care to a patient you don’t truly see. Too often, medical providers aren’t even taught how to look at sexual and gender minority patients.
“A physician is obligated to consider more than a diseased organ, more than even the whole man—he must view the man in his world” said Harvey Cushing, a pioneer of American neurosurgery. Leaving aside the gendered language, the sentiment remains true. In medical school, you’re cautioned to see your patients as entire human beings and not to reduce them to a mere collection of symptoms or diagnoses. Viewing them through the narrow gauge of their illnesses alone limits a provider’s ability to care for them comprehensively.
But learning to view LGBTQ people within our own particular world has been largely absent from medical education. By failing to incorporate material about the specific needs of gender and sexual minority patients into their curricula, medical schools have produced graduates who are less aware of those patients’ needs. This lack of awareness can have measurable ill effects.
Earlier this month, a study in JAMA Internal Medicine documented a wide discrepancy between how doctors perceived asking patients about being LGBTQ, and how patients themselves responded to such questions. Noting that both the Joint Commission and the National Academy of Medicine recommend asking patients about their gender and sexual identities, the authors conducted a survey of emergency department (ED) physicians and nurses, as well as potential ED patients, including gay, lesbian, bisexual, and straight respondents. (Technically, everyone is a potential ED patient, after all.)
About 80 percent of ED health care providers believed that patients would refuse to answer questions about their sexual identity. Just 10 percent of patients said they would actually do so. Only bisexual respondents were less likely than their straight counterparts to respond to such questions (which I interpret as a reflection of biphobia within both straight and gay communities).
In its report on the study, the New York Times quotes Dr. Adil H. Haider, the lead author, reflecting that the providers’ attitude “was mostly paternalistic: ‘We don’t want to make anyone feel different.’ But it turns out to be that, ‘Doctors, you may have the best of intentions, but your patients want to be asked.’ ”
“Patients are saying that you’ll make us feel more comfortable if you ask—and ask everyone, so that normalizes the questions,” Haider continued.
This new study isn’t the first report of physicians failing to ask their patients about sexual identity. A survey of gay and bisexual men conducted in 2014 by the Kaiser Family Foundation found that 47 percent of respondents had never discussed their sexuality with their physicians. As I wrote at the time, “By treating questions about being gay or bisexual as too embarrassing to ask, we merely reinforce the idea that they are shameful and allow the stigma to remain.”
If medical schools never teach students how and why to ask patients about sexual and gender identity, those questions will always seem foreign and foreboding. The consequences of failing to ask, and not knowing what to do with that information once gathered, have the potential to be catastrophic.
In a devastating article about the ongoing HIV epidemic among black gay and bisexual men, the Times notes that only about 10 percent of prescriptions for PrEP (a medical regimen that can prevent infection with the virus) are written for black men. In addition to lacking basic access to care, many of these men do not feel safe discussing their sexuality with providers, and many providers are unfamiliar with PrEP. Without doctors who know how to create a safe environment for disclosure of vitally important information about their patients and are up-to-date on the medical care of LGBTQ people, an underserved population of gay and bisexual men will continue to go without potentially life-saving medication.
Thankfully, medical schools are increasingly recognizing how important it is to include LGBTQ health in the education they provide.
“Over the past decade, schools have absolutely become more receptive to the need for improved LGBTQ health education,” Dr. Kristen L. Eckstrand, a psychiatry resident at the University of Pittsburgh, told me. As a medical student at Vanderbilt University, Eckstrand was co-director of the medical school’s Program for LGBTI Health, and chair of the Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development for the Association of American Medical Colleges (AAMC).
“This [increased interest] is due do many factors,” Eckstrand continued, “including students’ desire to take on scholarly projects towards understanding [other] students’ knowledge and attitudes regarding LGBTQ health, recognition of the importance of this topic by curriculum faculty and administrators, and release of recommendations by national regulatory bodies supporting improvement in medical training on LGBTQ health.”
In 2014, the AAMC released a comprehensive resource for medical educators to help improve the care of patients who are gender or sexual minorities. It offers a detailed description of how medical schools can recognize institutional barriers to creating an LGBTQ-friendly environment for learning, and how to implement curricular changes to better serve not only LGBT people but also those born with different sexual development (DSD), something about which my own education is seriously out of date. (DSDs have often been described as “disorders of sexual development,” which is language the AAMC avoids.) Clinical topics range from HIV risk factors in gay men, to a DSD man suffering from “corrective” surgical trauma from after birth, to a child with same-sex parents, among several others.
“Our goal is to ensure that this topic is not siloed, but instead is embedded throughout the curriculum, similar to any other important topic,” said Laura Castillo-Page, AAMC senior director for diversity policy and programs. “We want to ensure that there is not solely an optional course which everything gets dumped into. We believe a more holistic approach works best for all diversity-related topics.”
In addition to the 2014 publication, the AAMC has an extensive range of online resources for medical education. These resources include videos and webinars devoted to all aspects of LGBTQ health care, from faculty development to clinical vignettes to enhanced focus on LGBTQ and DSD issues in research, and range from introductory to advanced degree of familiarity with the various topics.
“We have developed various types of webinars on this topic, for a range of audiences and experience levels. Some are more introductory and include topics such as what does it mean to be transgender” said Castillo-Page, “what’s the appropriate terminology, how to take a medical history of a patient, and how to best collect data.”
As more new physicians learn these skills as a basic part of their education, the health needs of LGBTQ people will be better recognized and met. Simply learning how to ask patients about their sexual and gender identity as matter of routine would be a good first step.
Despite the encouraging trend over the past several years, Eckstrand identifies several ongoing barriers to widespread change. Due to lack of national standards for teaching the topic, experiences vary widely from school to school. In regions where the LGBTQ population is less present or the climate is more hostile, opportunities for supervised patient care can be limited. Similarly, few schools directly assess students’ skills in delivering care to sexual and gender minority patients, relying more on methods like multiple-choice testing. Finally, she notes the “hidden curriculum” of lessons students learn if they are in an institutional culture that is discriminatory against LGBTQ people, which reinforces bias against sexual and gender minority patients.
The work that remains notwithstanding, it’s encouraging to see how much more attentive medical schools are to these aspects of patient care than when I was in school myself. The needs of gender and sexual minority patients can’t be met so long as those needs are invisible. Learning how to see us in the first place is a necessary step toward equitable health care for LGBTQ people.