Shorting LGBT People on Medical Care

Medical schools in the US and Canada are giving short shrift to the medical needs of LGBT patients, according to a study by the Stanford University School of Medicine which is published in the Journal of the American Medical Association.  One needs to be a JAMA subscriber to actually read the report.

The web-based survey was submitted to 176 medical school deans in the US and Canada, with an 85% response rate.

The average amount of time spent teaching the potential doctors about health issues facing LGBT patients is about 5 hours over the entire curriculum.

Although many medical schools do address some LGBT-related health issues in their curricula, the conversation needs to go deeper, said the study’s lead author, Dr. Juno Obedin-Maliver, of the University of California, San Francisco.

These are misconceptions in the public at large and because there isn’t specific education in medicine about it, doctors-in-training – who are just people in society – don’t get disavowed of their social thinking about this group.

–Dr. Juno Obedin-Maliver

70% of respondents described their school’s coverage of 16 LGBT-related topics, like HIV and STIs, gender identity, and mental health issues as “fair”, “poor” or “very poor”.

While 97% of medical schools teach their students to ask patients if they have sex with men, women, or both when taking a sexual history, only 72% stated that students are taught the difference between behavior and identity, like men who have sex with men but identify as straight.

Without adequate education, the study’s authors suggest new doctors are often left with fallacies about lesbians and gays that are rampant throughout society.

One of the common misconceptions is that lesbians don’t need regular pap smears to screen for cervical cancer because they believe that HPV cannot be spread from a woman to a woman, which is not true.

Another often-overlooked issue is lesbians, compared to straight women, tend to have higher rates of breast cancer as they tend to have fewer children. Research has linked having children as playing a role in reducing the risk of developing breast cancer, said Obedin-Maliver.

LGBT people don’t necessarily feel comfortable talking openly about their life to a doctor, and that can lead to difficulties in treatment if you don’t have accurate information.  But most patients will talk about things if their providers are really openly interested and wanting to learn from their patients.

–Dr. Obedin-Maliver

The JAMA issue which hosts the report includes an editorial by Dr. Raymond Curry, vice dean of Northwestern University’s Feinberg School of Medicine in Chicago.

Curry, who wrote an editorial on the study, said the researchers’ method of calculating hours spent on teaching LGBT-related issues in the curriculum avoids some key questions about campus culture.

Are there educational leaders or course directors that are gay or lesbian, or that are clear allies who speak to the issue?  Seeing what the range of responses would be, whether there are easily identifiable faculty that students can relate to has a lot to do with how open and free the discussion is about patients’ issues.

–Dr. Raymond Curry

Since this study asked deans to judge their own schools, it is expected that things are even worse than reported.  It was expected that the deans would tend to round up.

So what happens after medical school with the way LGBT patients are treated?  We become reluctant and underserved.

[Physicians] may not think this applies to [them] but I promise you, almost every doctor who has patients, especially in primary care, has LGBT patients. They just might not know it because the patient doesn’t feel comfortable talking about it.”

–Robert J. Winn, MD, who teaches at Jefferson Medical College of Thomas Jefferson University in Philadelphia

It is estimated that 8.8 million Americans are lesbian, gay, bisexual, or transgender.  It is likely that the number is much larger, but nobody actually collects data on that and in addition many people refuse to identify their identity for fear of discriminatory reprisal.

Dr. Winn sees patients at a Philadelphia health center where he works.  Most are transgender.  Some are lesbian, gay, or bisexual.

Dr. WInn is himself bisexual and married to a woman.

What is really different about his practice is that his patients live up to 500 miles away…in towns stretching from upstate New York to southern Virginia.  What his patients looked for in a physician before choosing him was someone.

It’s ridiculous to get health care from 500 miles away,” but they don’t have anywhere else to go.

–Dr. Winn

Besides those who are at higher risk of STIs such as HIV, LGBT people are also more likely to smoke, use alcohol or other drugs, be overweight, attempt suicide, and engage in other risky behavior.  That’s what happens when a person is told by society that their life has little value.

Twenty-eight percent of transgender and gender nonconforming people postponed medical care when they were sick or injured due to concerns about discrimination, said a 2010 survey of about 7,000 people by the National Center for Transgender Equality and the National Gay and Lesbian Task Force. Gender nonconforming individuals are defined as people who do not fit stereotypes about how they should look or act based on the sex they were at birth.

More than one in five LGBT adults withheld information about their sexual practices from their doctor or other health care professional, said a 2004 survey by Witeck-Combs Communications/Harris Interactive.

Nearly 40% of lesbian, gay and bisexual people put off medical treatment because they are concerned about the cost of health care, and nearly 40% said they do so because of a lack of adequate health insurance, according to a 2005 Harris Interactive survey of more than 2,000 adults (patients could give more than one answer). One in five LGB individuals delayed care due to a bad experience with a health professional, and 15% did so because of concerns about discrimination.

Physicians who specialize in LGBT care don’t believe that their fellow doctors intentionally discriminate, but rather lack education about this group of patients.

For example, experts encourage doctors to place LGBT literature in waiting rooms and to post nondiscrimination statements that include gender identity and sexual orientation.

Experts note, however, that there are some instances in which health professionals knowingly are biased against LGBT individuals.  Some of Dr. Winn’s patients told him about being scolded by physicians for identifying themselves as LGBT and doctors offering them information “about how to not be gay.”

It’s just an awareness issue.  We don’t need to make huge, major changes. People are just afraid of things they don’t know.

–Joe Freund, MD from Des Moines, IA, who is gay

The consequences of not identifying this population are missed opportunities for preventive care that probably lead to increased rates of morbidity and mortality among LGBT patients, said Dr. Magda Houlberg, chief medical officer at Howard Brown Health Center in Chicago. The center specializes in treating LGBT adults and youths.

As an example of underserving our community, I note that the CDC periodically surveys schools to determine the atmosphere for LGB students…but has so far refused to include transgender youth in its studies.

Transgender people are among the most at risk in the LGBT population, and many are victims of violence, Dr. Houlberg said. For preventive care of this population, Dr. Winn recommends that physicians follow screening guidelines for the body parts the patient has. For example, if a person who was born a man has breasts due to hormone treatment, doctors should follow mammography guidelines.

AMA policy calls to discrimination against physicians, students, and patients because of their gender identity and supports educating doctors about LGBT research and health issues.

In a 2005 survey, 22% of lesbian, gay and bisexual people said they felt discriminated against in some health care settings.  Respondents could give more than one answer.

16%: Doctor’s or other health professional’s office

15%: Public health department or clinic

14%: Hospital

9%: Community health center

4%: Other health care setting

Note: The survey did not include transgender patients

The Association of American Medical Colleges recommends that medical schools ensure students master “the knowledge, skills and attitudes necessary to provide excellent comprehensive care” for gay, lesbian, bisexual and transgender patients.

For my own part, when I lived in Arkansas, I was interviewed on video by a faculty member (and parent of one of my students) at the University of Arkansas for Medical Services about what being transsexual is all about.  I was told that the video would be seen by students in their medical ethics course.

Since then I have had to teach most of my physicians how to treat me and in most cases their ethics was not the major concern.  It was their general lack of knowledge.


    • Robyn on September 10, 2011 at 00:06

    …to “cure” us.

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