Health out of the closet
A new mother visits her doctor because of a painful mass in her right breast. She has just finished weaning her 1-year-old infant and wonders whether the pain could be related to that or to something more ominous, such as cancer.
The woman did not mark "married" on the intake form, but she is accompanied by her partner, another woman, and they both wear wedding bands. When the doctor takes the sexual history, he asks if she is sexually active with men, women, or both. She says she is monogamous with her partner. The doctor then asks who the "real mother" of the baby is. The partner instantly becomes hostile. The implication is that only a biological mother could be a "real mother."
What should the doctor do now to remedy this delicate situation? And what should the doctor tell the patient? She had just read a magazine article saying lesbians have an increased risk of breast cancer, and she fears that her mass could be malignant.
This clinical scenario came up recently in one of my medical school classes at the University of California-San Francisco. It's part of a new addition to the curriculum on gay, lesbian, bisexual, and transgender health. Yes, San Francisco happens to be home of the Castro neighborhood, the nation's ZIP code most heavily populated with gays. It is not so unusual then that UCSF has chosen to incorporate these progressive ideas into medical education.
But the timing is ripe, too. Nationwide, there is growing momentum for healthcare providers to recognize the unique needs of this population. Indeed, the movement has an acronym, LGBTI, for lesbian, gay, bisexual, transgender, and intersex health. According to Shane Snowdon, director of LGBTI resources at UCSF, it's part of a broader effort in medicine "to recognize the rights of people--such as women [and] ethnic and racial groups--who have been historically discriminated against."
Risk factors. Researchers are now studying these groups as well. Up to 50 percent of adult gay men are smokers, for example, compared with 28 percent of men in the general population. Lesbians indeed have a slightly increased risk of breast cancer compared with heterosexual women, possibly because many have not had children. They also undergo less frequent Pap smears despite needing them just as much as heterosexual patients.
The push at UCSF to pay more attention to these issues in medical education began almost two years ago when several students petitioned the administration to update an antiquated curriculum. "Discussions about gays and lesbians had been pretty much absent," says Karl Jeffries, a fourth-year student who recently adopted two boys with his partner. "I just wanted to get some dialogue taking place about how their health might be different."
Nearly 40 students signed a letter asking administrators to consider several changes. For one thing, they asked professors to stop calling "homosexual sex" a risk factor for HIV and other sexually transmitted diseases. "It's outdated terminology," says Genevieve Preer, a fourth-year student who is a straight ally for these groups. "Referring to 'homosexual sex' as a risk factor implies that only gay men are at risk for sexually transmitted diseases. It's the behaviors that put everyone, including women, at risk."
Advocates also wished for mention in the curriculum beyond the stereotypical context of infectious diseases. What about other healthcare issues specific to the LGBTI population? There is plenty to study, they say: the psychiatry of "coming out," the consequences of high body-mass index for lesbians, the high rates of substance use in both gays and lesbians, and geriatric concerns, such as the decision-making power of partners during end-of-life care.
The administration responded amenably, funding a task force to examine ways to infuse these issues into the school's four-year curriculum. Even while that study is going on, professors have stopped using cultural labels and instead use specific descriptive language, such as "MSM" --or men who have sex with men--that details risky behaviors. They have also added more class time on how to take an information-rich and nonjudgmental sexual history.
The case about the lesbian was loosely based on a real situation in which the physician had to redeem himself after alienating a lesbian couple. How the doctor ultimately did make up for his foul-up I do not know. Yet one of my classmates--in response to how one could fix this faux pas--suggested, "Don't get into it in the first place." Now that's something we can do.
This story appears in the September 13, 2004 print edition of U.S. News & World Report.
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