Posted on January 22, 2019 at 5:31 PM
by Craig Klugman, Ph.D.
While serving as a faculty member at a medical school in Texas, I married my now husband. I did not announce this but many of the students found out and celebrated because this made me one of the few “out” people at the medical school. I was invited to be one of the faculty advisors of the LGBQTI (lesbian, gay, bisexual, queer, trans, intersex) student organization because even though I was newly out, there were very few potential role models for these future health care providers. One of the group’s projects was to increase the LGBQTI health content in the curriculum (from none). We found that there was little information available, few existing resources for students, and even fewer people who could teach the material.
A decade later, students are still asking for curriculum around helping their future LGBQTI patients. Care providers receive, on average, 5 hours on these topics, and most report feeling underprepared for working with the LGBQTI communities. To fill in part of this gap, NPR recently reported on student-driven efforts at Harvard and in the New York City area to increase learning about LGBQTI health. The goal is not to have separate units on how to take care of this population, but to integrate this knowledge into the mainstream curriculum. The American Medical Student Association has taken a lead in these efforts. Their website offers some tools for helping students to advocate at their medical schools: A “card” provides advice for organizing students to work with their administration. The main focus is on the “Plus One” initiative—the goal being to add one hour of LGBQTI health to medical school.
Although we are all humans, the LGBQTI population faces discrimination not only in society but also from their families and in their health care. Consider that just today the Supreme Court removed lower court orders that had stalled Trump’s military transgender ban. As of January 22, 2019, people who identify as transgender are no long welcome to serve their country. Like the previous “Don’t Ask, Don’t Tell” policy, the ban applies to people who want to transition. If you try to “pass” and keep your identity in the closet, then one can serve.
According to HealthyPeople2020, individuals who are LGBQTI have higher rates of psychiatric problems, substance abuse, and suicide rates. Violence, victimization, and family problems also contribute to health problems. Rates for cancers, risks for certain diseases, and social isolation are different than for the cis-gender, hetero population. Additionally, people who identify as LGBQTI are more likely to experience discrimination in life (e.g. housing, employment), including in their health care: One in six report having avoided seeking medical care out of concern that they would be discriminated against. We often hear of worry that an individual doctor will harass or threaten, but we must also focus on the structural discrimination in institutions. For example, a surgical colleague who regularly performs transition surgeries was recently told by her hospital that such cases could no longer be performed there since the whole idea conflicts with their “philosophy”.
When my primary care physician retired, she recommended one of her colleagues, a doctor who was also gay because she thought I would be more comfortable. As a patient, it is easier to build trust with someone when I know I can talk about my husbandinstead of my spouse(until I know if I am safe with this person knowing), and raising personal issues without fear of being judged. However, I was also taken aback by her suggestion that she would assume I would choose a health care provider based on sexuality rather than on their practice excellence. On the one hand, there is a comfort with having common ground, but this is the equivalent of saying that your populationwill get better care if you go to someone from your population. Would we tell black patients to only go to black doctors? Or Hispanic patients to only go to Hispanic doctors? Or women to only go to female doctors? It is true that someone people prefer a doctor who looks like them. Moving from “you can see such a doctor”, to “you must see such a doctor” in order to get decent care, lets physicians off the hook for being able to care for all patients and puts the onus on the patient to avoid being the subject of discrimination: “You were mistreated by your physician because you do not choose the right physician.” Such thinking reinforces the idea that medical school does not have to teach minority health issues because those patients will see people with similar lives who specialize in them. All physicians should be able to sensitively, compassionately, and honestly treat all patients no matter their sex, gender, religion, ethnicity, race, age, or sexual orientation. Medical schools need to teach how to care for a diverse population.
The lack of LGBQTI medical curriculum not only effects patients, it effects medical providers. A UK study found that 70 percent of LGB doctors faced “discrimination, harassment and abuse… 12 percent of respondents had directly experienced harassment relating to their sexuality, ranging from verbal abuse to threats of violence.” A U.S. study found that thirty percent of med students also remain in the closet out of fear of abuse and discrimination. While I was at the medical school in Texas, a colleague from another university and I started a research project interviewing medical students and physician faculty identifying as LGBQTI about their experiences in the world of medicine. After nearly a year, we had to abandon the project. While some med students were willing to be interviewed, we only found one faculty member in the target region who was willing to talk with us. Many were approached but turned down the interviews because they feared what would happen if people (colleagues and patients) knew they were LGBQTI. Showing them the steps we were taking to protect their confidentiality were not helpful, outweighed by a lifetime in a professional culture that denigrated them.
Bioethics is not much better. Publications on LGBQTI bioethics concerns do not appear until the mid-2010s: A special report in the Journal of Bioethical Inquiry (2012), Journal of Medical Humanities (2013), Hastings Center Report (2014) and a special issue of the Journal of Homosexuality (2015). Only in 2010 did a bioethics center adopt a focus looking at LGBQTI bioethics in the form of the University of Pennsylvania’s Queer Bioethics project. Like medical curriculum, however, minority health issues should not have to be a “special issue,” these examinations should just be part of bioethics and appear in many issues, even as standalone articles.
How many people never pursue careers in health care because of these fears? A student-led Stanford project has recommended efforts to increase the number of LGBQTI students applying to (and presumably matriculating into) medical school. Back in 2011, Yale medical school targeted the LGBQTI population for admissions witha special brochure, an effort that seems minimal at best. As the medical students with whom I worked told me, they wanted to see role models who resemble themselves and who could serve as examples of succeeding as health care professionals who identify as LGBQTI. The importance of creating an environment that supports all minority health care providers is important to caring for patients, colleagues, and ensuring a new generation of practitioners trained to inclusively treat all people.
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