While I should have been out at the gay clubs, I spent far too much time developing a vitamin D deficiency in the underbelly of my university’s library. There I spent time looking through every year of the Index Medicus prior to electronic indexing in MEDLINE for articles on the pathology of homosexuality. Indexed by the Office of the Surgeon General and the Carnegie Institute under terms such as “sexual deviation” and “sex instinct, inversion of”, you get a sense of the tension between medicine and movements for lesbian, gay, bisexual, and transgender (LGBT) equality. Doctors were some of the first allies in saying that homosexuality should not be punished as a crime, rather homosexuality was an unfortunate pathology that deserved compassion. Later psychiatrists became the target of LGBT rights movements, as we strove to shake the association with disease and have sexual orientation removed from the Diagnostic and Statistical Manual of Mental Disorders. As studies began to sample from the community instead of psychiatric institutions,1 medicine started to hear the challenges of being gay in the U.S. and see gays and lesbians as people. Today, medicine, at its best, is an ally in addressing persistent health inequalities that are increasingly recognized as being socially determined, rather than intrinsic, among LGBT people2. Thus, there is a long and somewhat rocky relationship between homosexuality and medicine.
Just going back a few decades to the 1980s shows how stories of mistreatment abounded. Community surveys of lesbian and gay communities in this time show frequent responses of poor treatment at the hands of physicians when gay or lesbian identity was disclosed.3 Yet, community organizing against the HIV epidemic, educational efforts, and the development of a number of LGBT health centers across the nation helped change this. Work by advocates and researchers made possible special issues of LGBT health beyond HIV as early as 2001 in the American Journal of Public Health and even earlier in a state medical journal: the North Carolina Medical Journal dedicated a special issue in 1997 to lesbian and gay health.4,5 In broad strokes, medicine as a field has developed over time from ignoring homosexuality, to rejecting it outright, to trying to cure it, to begrudgingly accepting it, and, in our current era, to working to ameliorate social injustices that cause morbidity and mortality.
I do not speak for the LGBT communities, but I have listened to many stories. Medicine’s coming out as an ally parallels identity development among your patients. I, for example, spent years denying that I was gay. Surely everyone else found men to be attractive as I did. Surely my eye caught the curve of a handsome male bicep only because I wished to have such definition. In the rural Appalachian mountains of North Carolina, I watched others get tormented in high school for being perceived as gay, and I reassured myself that, surely, I was straight. It took time and a kiss from an attractive man for all of my willful ignorance to fall away. Then followed all of the awkwardness of re-shaping my identity to recognize that I was gay, telling all of the relatives, changing people’s expectations, and figuring out where I fit in the LGBT communities. I was lucky to have supportive parents and a few relatives who came out long before I. The horror of someone thinking I was gay gave way to awkward disclosures, which, in turn, has given way to my sexuality being such a natural and core part of who I am. I no longer think about my sexuality as part of my identity any more than I think of my race or gender. That is, unless I am faced with epithets from passing pickup trucks, as periodically happens, or when my state votes to makes rights I did not even have even more distant. (North Carolinians just voted to pass a constitutional amendment restricting marriage to opposite sex couples.)
Some of your patients may still be in denial about their sexuality. For some of us phases of anger or sadness are longer or more pronounced than others. Some of us cope in ways more self-destructive than digging through the Index Medicus. Some of us try to change who we are. Some of us cannot see any future. As identity matures and settles, lives are punctuated less by changes in who one is than by the discrimination and violence that people face from being different in America. I have yet to meet anyone who has not faced some discrimination or violence along the way. The research literature also suggests that a myriad of health risks are not randomly distributed in LGBT people’s lives, but are likely concentrated in particular vulnerable periods. It is likely that some of the early stages of identity development are among these periods. As the age of coming out goes down, coming out may interact with the challenges of puberty, developing an adult identity, and all of the associated challenges. We already know that cementing healthy behaviors during identity development is a key concern. The tobacco industry also knows this and targets college student and young adults heavily to cement experimentation with tobacco products into part of an adult identity.6 Building healthful choices and promoting self-worth and a vision of one’s future are key pieces of this identity development process.
Similar to both the field of medicine and your LGBT patients, you may find that straight people develop their identities as allies to LGBT communities, moving from no knowledge, to pity, and to acceptance and understanding. It is never quite as orderly and neat as the identity development models make it sound, but you may find discernable stages among your colleagues and staff. Several resources exist for this process. In particular, PFLAG or Parents, Families and Friends of Lesbians and Gays provides resources for many a family member of LGBT people. The Human Rights Campaign provides a pamphlet titled A Straight Guide to GLBT Americans that is easily found online. Candid discussions with friends and relatives can tell you more.
A recent survey by the Network for LGBT Health Equity asked about LGBT people’s experiences with quitting and using telephone cessation coaching. The responses provide a reminder of the importance of meeting people where they are and engaging on how LGBT lives may provide unique triggers or stressors for smoking. One woman noted, “I would appreciate it if the counselor acknowledged and offered suggestions for how I can examine my same-sex (lesbian) relationship as a large stressor and trigger for smoking.” Another noted discomfort in the coaching session: “Just felt uncomfortable talking about all my barriers related to quitting (partner is still smoking).” Still a third noted that that a better experience could be achieved simply with having “somebody on the other end that wants to help.” One gay man noted, with pleasure that, “When I mention my husband the quit coaches quickly and comfortably have used that label when referring to him.” These brief experiences with telephone-based coaching provide some examples and reminders for the clinical encounter.
So, for all of the great benefits of using checklists, practice guidelines, and implementing clinic systems, one challenge for every clinician is the art of knowing where patients are in their development and building rapport. I have no great secrets to accomplish this other than the art of listening, communicating an acceptance of difference, and creating welcoming clinic environments. Additionally, clinicians have their own journeys to travel in building acceptance and empathy with LGBT patients, family members, and friends. In a medical home, you will have both the joy and the challenge of following this journey and providing needed care along the way.
Improving the Health Care of Lesbian, Gay, Bisexual and Transgender (LGBT) People: Understanding and Eliminating Health Disparities
The National LGBT Health Education Center, The Fenway Institute, Fenway Health, 2012 Download PDFReferences:
1. Hooker E. The adjustment of the male overt homosexual. Journal of Projective Techniques. Mar 1957;21(1):18-31.
2. Epstein S. Targeting the state: Risks, benefits, and strategic dilemmas of recent LGBT health advocacy. In: Meyer IH, Northridge ME, eds. The health of sexual minorities: public health perspectives on lesbian, gay, bisexual and transgender populations. New York: Springer; 2007:149-168.
3. Lekus IK. Health care, the AIDS crisis, and the politics of community: The North Carolina Lesbian and Gay Health Project, 1982-1996. In: Black AM, ed. Modern American Queer History. Philadelphia, PA: Temple University Press; 2001:227-252.
4. Halperin EC. Why a special issue of the North Carolina Medical Journal on gay and lesbian medicine? N C Med J. 1997;58(2):90-91.
5. Halperin EC. The North Carolina Medical Journal finds itself in the vanguard of progressive medical journalism or, the deputy editor finds his fifteen minutes of fame. N C Med J. May-Jun 1999;60(3):138-139.
6. Ling PM, Glantz SA. Why and how the tobacco industry sells cigarettes to young adults: evidence from industry documents. American Journal of Public Health. Jun 2002;92(6):908-916.