{"id":2350,"date":"2017-09-27T11:41:34","date_gmt":"2017-09-27T15:41:34","guid":{"rendered":"https:\/\/blogs.nejm.org\/general-medicine\/?p=2350"},"modified":"2017-09-27T11:41:34","modified_gmt":"2017-09-27T15:41:34","slug":"thoughts-on-caring-for-lgb-patients","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2017\/09\/thoughts-on-caring-for-lgb-patients\/","title":{"rendered":"Thoughts on Caring for Sexual-Minority Patients"},"content":{"rendered":"
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David Herman, MD, is a 2017-18 Chief Resident in Internal Medicine at the University of Southern California \/ LAC+USC Medicine Center in Los Angeles<\/p><\/div>\n

According to recent polling, approximately 4% of the population of the U.S. identifies as gay, lesbian, or bisexual, which equates to more than 10 million people scattered from coast to coast. In truth, this number likely underestimates the true prevalence. Despite the progress that we have made as a nation towards LGB acceptance and equality, people who identify as LGB still experience discrimination and hate, such that many feel pressured to remain \u201cin the closet.\u201d Even those who do open that closet door often live in the daily reality that, in many ways, in many minds, and in many places, they remain second-class citizens.<\/p>\n

I am one of them, a gay man who lives in West Hollywood, California. \u00a0I count myself fortunate in that I have lived, worked, and studied among accepting individuals and in accepting institutions; aside from the adolescent and early adult struggles that I experienced prior to coming out \u2014 teasing and name-calling, feelings of inadequacy, fear of disappointing those around me,\u00a0all of which are relatively common amongst my LGB peers \u2014 I have emerged relatively unscathed and now live a life in which I feel supported, and which gives me opportunities that I am thankful for on a daily basis.<\/p>\n

\"Albuquerque<\/a>

By Kaldari (Own work) [CC0], via Wikimedia Commons<\/p><\/div>Yet, I am reminded frequently that my sexual orientation classifies me as a vulnerable minority. \u00a0The recent rescinding of protections for transgender military personnel (Note: my omission\u00a0of transgender individuals prior to this is intentional, as I believe that the topic of transgender people and their healthcare deserves special attention: I will be addressing that in a future blog)<\/em>, the numerous attempts to pass \u201cReligious Freedom” bills around the country, and the still deep wounds inflicted by the senseless tragedy in Orlando, Florida, for example, remind me that we still have far to go to achieve true equality, legally and beyond, and that we remain in many ways, the targets of a discriminatory society. I am further reminded of this when I read the news or watch the talking heads debate our rights on cable television \u2014 as though arguments to codify our status as second-class citizens are valid ones to be discussed and are not simply discriminatory statements. And all of these things are contributing factors in the overall poorer health of LGB youth compared\u00a0with their heterosexual peers.\u00a0Mental health, especially, is affected:\u00a0studies have demonstrated significantly higher rates of mood and anxiety disorders, higher rates of depression, and a dramatically higher rate of suicide attempts and ideation amongst LGB people.<\/p>\n

So, as a gay man,\u00a0I do the best I can to channel my feelings into promoting and expanding the health and welfare of my community. As a gay doctor, however, this strikes a different chord in me. It is not solely because of obvious health disparities that exist amongst members of the LGB community, although they are real and extensive and, many times, inadequately addressed in healthcare settings (NEJM JW Gen Med<\/em> 2016 Aug 1<\/a> and JAMA Intern Med<\/span> <\/em>2016; 176:1344<\/a>). Higher rates of sexually transmitted infections in men who have sex with men (with the growing emergence of antibiotic-resistant organisms), dramatically lower rates of adherence to national guidelines for cervical cancer screening amongst lesbian women, higher rates of smoking and substance use and abuse amongst LGB people in general \u2014 these should be of concern to all physicians in Internal Medicine, especially as we shift more of our focus toward preventative care. The National LGBT Health Education Center<\/a>, a program of the Fenway Institute, has a tremendous amount of resources to address some of these specific concerns, and I would challenge you to access their materials to educate both yourself and your peers and keep up to date on very pertinent issues that affect your LGB patients.<\/p>\n

LGB Patients Sometimes Fear the Healthcare System<\/h2>\n

\"Rainbow<\/a>My fear is that those of us in the medical profession avoid many\u00a0basic issues of sexuality and orientation. In 2003, for instance, a survey published in the Journal of Homosexuality <\/em>revealed that 71% of medical residents did not regularly ask sexually active adolescents about sexual orientation; when pressed, 93% reported that this was because they were too uncomfortable to do so (J Homosex <\/em>2010; 57:730<\/a>). In 2002, 6% of physicians surveyed by the Kaiser Family Foundation <\/a>reported that they were uncomfortable treating gay or lesbian patients<\/a>.\u00a0Attitudes can\u00a0change, of course, and these surveys were conducted over a decade ago. Yet, a recent publication in the American Journal of Public Health<\/em> revealed that amongst 200,000 surveyed healthcare providers, including physicians, implicit preferences toward heterosexual patients over members of the LGB community existed among heterosexual providers\u00a0(Am J Public Health <\/em>2015; 105:1831<\/a>). This\u00a0attitude (whether conscious or unconscious) further solidifies\u00a0the already thick wall that exists around many LGB people, one built of distrust for the medical profession due to fear of judgment or discrimination and a history of both: It was not long ago that we doctors classified homosexuality as a mental disorder. And these fears\u00a0are present\u00a0even among our peers:\u00a0A 2015 study in Academic Medicine <\/em>concluded that sexual and gender minority medical students\u00a0often conceal their identity during training (nearly 30% of such students), with nearly half of concealing students reporting\u00a0fear of discrimination (Acad Med<\/em> 2015; 90:634<\/a>).<\/p>\n

Clearly,\u00a0we need to do better, for our patients and for ourselves. The first step in addressing the many health disparities that exist in the LGB community is to confront the issues that we, as a medical community, have with sexuality and orientation. That is where we, as residents, especially as residents in Internal Medicine, can take a special role. Residents are the next wave of attending physicians in community and academic centers across the nation, and we\u00a0have the opportunity to re-create atmospheres that have traditionally been less than inviting to those with differing sexual orientations. Furthermore, as residents now, we are often the first ones to take\u00a0full histories for our patients, the first one to see them in the ambulatory setting, and the ones that strategize with them to establish\u00a0treatment or follow-up plans, which leads to continuity and building of\u00a0lasting relationships. To do this well, we need to know our patients; and this includes understanding their sexual orientation and how it directly and indirectly affects aspects of their lives. I can recall the first time that my physician asked me about my sexual orientation; it changed our therapeutic relationship immediately as I felt a comfort level as of then unachieved, and allowed me to discuss issues openly and honestly to the betterment of my own health.<\/p>\n

Caring for LGB Patients<\/h2>\n

So\u2026 what are some steps that we as medical professionals can take?<\/p>\n