LGBT health care equality: Be your patient’s advocate

The fight for equality for lesbian, gay, bisexual, and transgender citizens has been a long and storied one. We have fought for rights related to family, marriage, anti-discrimination and service to our country.  We have reveled in the freedom to be openly ourselves in public and have cheered as the fight for equality became a priority not only for ourselves but also for our straight allies.  As Rhode Island recently joined the fight for marriage equality, I couldn’t help but think about where we stand in the realm of healthcare equality for LGBT patients.

In 2007, the Human Rights Campaign (HRC) instituted a way of measuring quality, safety, and satisfaction of LGBT patients treated at both inpatient and outpatient facilities across the United States. The measurement was called the Healthcare Equality Index (HEI), a skillfully designed survey helping healthcare organizations to provide quality care to the LGBT community. The survey focused on 4 core measures: patient non-discrimination, equal visitation, employment non-discrimination, and training in LGBT patient-centered care.  Hospitals across the nation began to adopt the HEI and the Joint Commission recognized the growing need of advancing effective communication to this patient population.

The HEI was originally drafted as an improvement marker to address healthcare inequality towards the LGBT population. In a recent study from the HRC, When Health Care Isn’t Caring, 73% of transgender patients and29% of lesbian, gay and bisexual patients reported that they believed they would betreated differently by medical personnel because of their sexual orientation.  These numbers, though disconcerting, are not surprising. Even more disconcerting is the feeling of discrimination that some LGBT physicians describe from within their respective fields.

As an openly gay physician-in-training, I feel compelled to address the issues of modern-day medicine and the emotionality behind being both a member and provider of the LGBT community. Though much of what I see in my colleagues is encouraging, there still remains a lack of knowledge of the how-to of LGBT patient-centered care on the part of the providers. So where are we going wrong?

During my medical school basic science training, our LGBT health education consisted of a 5-minute blurb about sensitivity in history taking when questioning a homosexual male patient. This hardly constituted an “education” and left me confused and angry about why LGBT health wasn’t in focus. What about me wasn’t important? As I entered my clinical years, it became even more apparent that many health-care providers and fellow medical students lacked the cultural sensitivity that I innately expected from them.  What I later recognized was the culprit was a disparity in dialogue between LGBT patients and their physicians. But where was this disparity coming from? Was it simply a lack of knowledge of the patient population or was this hinting to a larger issue of an unspoken but well understood homophobia within the field of medicine?

A recent article by Dr. Mark Schuster (professor of pediatrics at Harvard Medical School and chief of general pediatrics at Children’s Hospital Boston) elucidated some of the sentiments that I sometimes am hesitant to say I agree with.   Medicine is a noble profession. We as providers chose to treat patients regardless of race, creed, political background, and undoubtedly sexual orientation. We are supposed to be selfless in intention and show the same amount of compassion to the CEO as we do to his janitor. To me, saying that homophobia exists in medicine is completely counterintuitive to what our profession stands for. They may both exist, but they simply cannot coexist.

As a resident in internal medicine, I’ve grown to embrace my role as health-care provider and more importantly my role as advocate for my patients.  After coming out to family and friends in medical school, I was scared about living openly and being judged by strangers. I realized that every time I asked my patients about their personal lives, I was putting myself at risk of being judged if they reversed the questioning.  It was in those moments that I learned the most about myself and about my patients.  Those moments allowed me to feel the vulnerability that my LGBT patients feel every time they enter a hospital front door.

The Healthcare Equality Index will continue to be a step in the right direction in helping close the gap between patient and provider.  Ultimately, medical school curriculum as well as residency awareness of LGBT patient-centered care will be relevant and necessary to further the dialogue. As physicians, we must realize that our role in caring for LGBT patients and families extends beyond our role as provider. In the political climate that we live in, progress will continue in every realm if we continue to voice our support of equality in our realm.  I’ve chosen to be an advocate for my LGBT patients and to stand on the right side of history.

Rashmee Patil is an internal medicine resident.

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  • Mika

    Americans Have No Idea How Few Gay People There Are: Surveys show a shockingly high fraction think a quarter of the
    country is gay or lesbian, when the reality is that it’s probably less
    than 2 percent.

    The Atlantic: http://www.theatlantic.com/politics/archive/2012/05/americans-have-no-idea-how-few-gay-people-there-are/257753/

    So how many hours of medical school DO you want devoted to such a rare condition?

    • ninguem

      What is desired is every second of every day in medical training must be devoted to My Pet Cause.

      And I will use the power of the Legislature to force it, as a condition of licensure.

      You may be a pathologist and never see a living human being, but you must take courses in My Pet Cause, even if it means you skip the course on reading Pap smears.

      Actually, we’ve been going through this for years. Some states have a crazy number of mandatory subjects to take for continuing education.

    • ninguem

      The higher perceived numbers of gays in the population, likely came from the Kinsey Report, which in fact used bad statistical methods.

  • Mengles

    This is the reason why medical education has been going down the tubes for decades and why older attendings complain that residents and medical students have decreased clinical knowledge when it comes to taking care of patients, and I myself believe fully in LGBT patients having their full civil rights. Instead of teaching actual medicine, we now use medical education as a vehicle for political gain, and yes the HRC is a political group, plain and simple. Then you have people such as this author, that then complain about how the curriculum doesn’t cover what they’re advocating enough, as if the medical school curriculum isn’t already packed to capacity. Shouldn’t we have an African-American curriculum as well? What about a Hispanic curriculum? How about keeping it simple and just treating patients as patients, not just bc of your insecurities Dr. Patil? How many hours you with should be given JUST for the LGBT medical curriculum alone? I will await your answer.

    • ninguem

      And to make it even more fun, since there are, in fact, medical conditions that are more common in gays…..excuse me, MSM…..then in fact the LGBT population will, in fact, be treated differently because they are…….different. So their perception that they will be treated differently is not unreasonable.

      • Mengles

        There you go using epidemiological facts again.

        • ninguem

          Not that there’s anything wrong with that.

      • leanne thomas

        I agree with you in part, ninguem. I would clarify, though, that they shouldn’t be treated badly, shamefully, or unkindly because of their LGBT status. A good doctor may need to ask direct and uncomfortable questions to address their medical needs while encouraging safe lifestyle choices. They can deliver this kind of care honestly, but with sensitivity. Any LGBT-identified person who wants to take responsibility for their healthcare will appreciate this approach.

  • equality

    As long as male patients have the right to refuse care from male homosexuals the way women have the right to refuse care from straight males then I don’t care. But alot of people don’t want to be treated by doctors whose gender/sexual orientation means they’re gonna be turned on seeing them naked and vulnerable.

    • trinu

      You can refuse to see any doctor for any reason, although it’s a bit odd to ask them what their sexual orientation is.

    • buzzkillerjsmith

      Women don’t refuse care from straight men that often, except for the gyn stuff sometimes. At least not enough to affect how busy I am. 70% of my pts are women.

  • leanne thomas

    I have to agree with the other commentors. As I read through your article I felt confused: exactly what were you asking for that was APPROPRIATE TO A MEDICAL EDUCATION? To me it seemed like you wanted to bring politics into the exam and hospital room and that is exactly what you are trying to GET OUT of the exam and hospital room – anything that interferes with the appropriate medical care of anyone, regardless of race, gender, sexual orientation, or socioeconomic status. That does not mean that we exclude the needs of certain groups of people that are flagged for medical issues relating to lifestyle. As an internist, there are certain things you are going to look out for with a sexually active, 19 year-old gay man than let’s say a 39 year-old married man with several kids. Is this wrong to do? Absolutely not. You are not making a judgement to shame or exclude, but to properly evaluate and treat. Leave politics out of the whole exchange between doctor and patient. If I have misunderstood you, then, by all means, set me straight.

    • P. Littleton

      I` agree, and would add that since teachers are in a position of power over students, and since doctors are often in a position of power over patients (or are seen to be), using the classroom or an exam room to push divisive political viewpoints can be seen as coming awfully close to bullying.

  • DavidBehar

    In Philadelphia, homosexual thugs attacked Christians handing out literature at a Gay Pride parade. The police then arrested the Christians, instead of the vicious thugs. Homosexuals make incomes a full standard deviation above the mean, according to the 2010 census, no doubt by earning them, That means the average homosexual makes more money than 86% of heterosexuals. No one may criticize let alone report anyone intentionally spreading an STD.without loss of job, imprisonment, fines.

    Why are gays so above the law, immunized and privileged by the lawyer? The lawyer owns government. The family is in competition for authority with the government Gay rights are part of an anti-family jihad by the lawyer. Most gays are doing well, are left alone, and do not any want activist pushing an anti-family agenda. So the entire movement is a Trojan Horse for left wing, straightforward hate America and hate family lawyer expansion of government powers.

    • P. Littleton

      “the entire movement is a Trojan Horse for left wing, straightforward hate America and hate family lawyer expansion of government powers”

      Nonsense. I am a Tea Party supporter, a libertarian-leaning conservative who believes in limited government, and also a supporter of gay rights. I was a great fan of conservative firebrand Andrew Breitbart, and as you may or may not have known, he was on the board of the Republican gay activist group GOProud.

      Gays are our brothers, our sisters, our daughters and sons. Whether or not you believe that politicized gay rights activism belongs in med schools and doctors’ offices, claiming that gays (and their friends and families) who just want the same rights as all of our other brothers, sisters, daughter, and sons must therefore “hate America” is both hurtful and wrong.

      • DavidBehar

        They have superior privileges, and legal protections no one else has. The idea that there is discrimination or a lack of rights others have is false propaganda. They have superior incomes, protections.

        Legalized same sex marriage is a lawyer idea, not a gay idea. In countries and states with gay marriage, very few have taken advantage and gotten married. Being gay does not make one stupid. Marriage is so tilted against the productive male, one has to be a fool to get married. Gays are not fools. Gay marriage will also make gays poorer and unemployable. If one cannot ask about the HIV status of the spouse, one will not hire a person whose spouse could bust the health budget of the small business. It will result in higher unemployment rates and drops in income from their superior level of today.

        If you want to help an oppressed segment of the population, help to defend religious people against government thugs. These police thugs are agents of the prosecution, i.e. lawyers.

        • P. Littleton

          “They have superior privileges, and legal protections no one else has. They have superior incomes, protections.”

          Not in all cases. Federal tax law, especially, discriminates in a number of ways against couples who are not married. Since Federal law does not recognize gay marriage, this includes all gay couples. My husband and I have a lot more options for arranging our affairs to benefit each other and our family rather than the tax-man, than my brother and his partner do. There are other ramifications in the legal, financial and medical spheres to not being married.

          But I didn’t mean to derail this comment section any further with a discussion about gay rights in general. To get back on topic, I broadly agree with most of the other readers’ comments here. I do think doctors need to be aware and sensitive to the /medical/ issues of their LGBT patients, but I think the political side of this, which we can see by your comments is a very fraught and emotional topic for many, doesn’t belong in the classroom or workplace. It is still legal for people to be personally opposed to gay marriage as long as they don’t break any anti-discrimination laws, and though of course I’d like to win them over to my side, I’d like them to be genuinely won over and not bullied into “saying the right things” while their hearts and minds are still opposed. The resentment that would cause will end up boiling over at some point, and that won’t be helpful for anyone.

    • buzzkillerjsmith

      Your comments are political and are irrelevant to what we docs do in the exam room or in the hospital. It is best to separate politics from medical care.

  • trinu

    Honestly, how long can it take to teach students to be polite and treat them like any other patient with whatever medical condition they’re presenting with? I seriously doubt lymphoma (or any other condition) is going to show different symptoms or respond differently to treatment just because a patient is gay.

    • liz margolies, LCSW

      As the executive director of the National LGBT Cancer Network, I know for sure that culturally competent care for LGBT patients involves more than politeness. “Treating all patients the same” does not take into account the relevant medical and social history of LGBT patients, many of whom have increased health risks, coupled with an avoidance of the medical system, due to previous negative experiences and feared negative consequences. In order to change this, the healthcare system has to reach out and show their welcome to this wary and underserved population.

      • leanne thomas

        Or, just provide competent and knowledgeable medical care with the awareness of their unique needs. An awareness of their unique needs doesn’t take that long, no longer than knowing the risks to people in poverty, the elderly, the at-risk youth population, etc. I am sorry, however, that any LGBT patient has had bad experiences just because of their sexual orientation. I am sure they have, and I am very sad to hear that. Your network serves a vital purpose then. I wish you well.

  • buzzkillerjsmith

    It makes sense to have LGBT issues discussed in medicine, but years ago, when I was in med school, we had a “sex weekend” in which a range of sexual practices and orientations were discussed, including gay matters. These issues were also discussed, to some extent, on the wards.

    I ask sexual orientation and practices for pts who come in for related symptoms but not routinely. Maybe I should. As you all know, disease prevalence differs in LGBT pts from prevalence in straights.

    All pts should be treated with dignity and respect.

    Overdoing the education and turning it into propaganda is counter-productive. Some gays seem not to realize this.

  • Keisa Bennett

    Hi Rashmee, excellent article, thank you. Are you a member of GLMA? We have an education committee and a student/trainee section who are concentrating on health professions education. I am also doing this work through Society of Teachers of Family Medicine and AAMC and AMSA are also making pushes that we are trying to coordinate. You may already be a part of these efforts, but in any case, if you’re interested in doing more, find me through the “GLMA Faculty” Facebook page if you have Facebook.

    The comments below demonstrate how far we have to go. Propaganda? Hardly. Do these folks know all the terminology for LGBTQQI, the basics of the WPATH standards, the cervical cancer guidelines for WSW, the group that has the highest incidence of HIV? (We find high levels of missing these questions in our workshops.) You can’t solve that with general “sensitivity” and it matters. And no matter how much training we get on asking “sensitive” sexual histories, I seldom see it put into practice. I still struggle with it because I got so little practice early on and rarely saw it demonstrated. (I’ve been faculty for 5 years.)

    I finally had to come out to my doctor 2 years ago. Not a single health provider had ever asked enough. They didn’t know the difference between sexual identity and orientation and behavior. So a few superficial questions about activity were all I ever got. For an ankle sprain or a cold, maybe no big deal. But I spent years feeling like I was hiding something from my PCP and getting all sorts of inappropriate preventive advice due to this “don’t ask, don’t tell.” Not propaganda to just want to have my doctor understand me.

    • Mengles

      Are you seriously going to say that AMSA and HRC don’t have a political agenda? Give me a break. Your surprise of getting “inappropriate preventive advice” when you were hiding pertinent medical information such as sexual orientation from your doctor does not merit revamping the medical school basic science curriculum, as this author wishes to do, which is already stretched to capacity for students studying for Step 1. If you are willing to do that for the LGBT community, then there is just as good of reason to have a white, black, Hispanic, and Asian medical curriculum as well. There is a reason students are more and more not picking primary care, bc people such as yourself and the author keep wanting to change the curriculum to promote, “My Pet Cause” (as mentioned by a poster below), rather than teach physicians to be astute clinicians.

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