From a student’s perspective:
Outing anti-gay biases in health care

by Will Narracci, D.O.’14, M.P.H.’14

LGBT individuals are individuals. They are people with whom we interact on a daily basis, people we already know, like and respect, who happen to be gay, lesbian, bisexual or transgender.

Picture yourself as a student having just begun your first year of clinical rotations. An adolescent patient sits with her mother in the exam room, and you stand next to your attending, raptly hanging on her every word. The attending moves through the standard process of taking a patient history, eventually asking the adolescent patient if she “likes boys,” to which the patient shyly replies, “No.” After a pause, the physician asks, “Do you like girls?”

It’s not clear if the patient answers out of anxiety to move past this part of the exam (understandable, for a 13-year-old), or if she is sincere in her reply. Regardless, she quickly says, “Yes, I like girls.” Another pause passes, the physician sighs in exasperation and remarks, “Well, that wouldn’t fly in my family.” The mother of the patient quickly responds, “Yeah, it doesn’t in ours, either.”

The physician moves on to another question, but you see through the body language of the patient that she has become emotionally withdrawn.

As the rotating student, you are unsure how to respond. The attending physician will be writing your evaluation letter in a few days; do you risk a potentially contentious discussion to make a suggestion of how to take an unbiased sexual history? Or do you let the comment slide, fearing that, as a student, it would be unwise to question the clinical strategies of your attending?

You suspect that, after her interaction with the physician, the patient may be uncomfortable sharing a sexual history in the future, and that this may have lasting effects on her overall health care. Unfortunately, you weren’t really taught how to approach these issues prior to rotations, and you aren’t sure what exactly those effects would be.

Over the past year, discussions began at DMU regarding the importance of increasing education and health literacy in the training of our future health care professionals with respect to lesbian, gay, bisexual and transgender (LGBT) patients. According to the Journal of the American Medical Association (JAMA), LGBT individuals have specific health and health care needs relating to chronic disease risk, adult and adolescent mental health, intimate partner violence, gender identity, sexually transmitted infections and HIV infection, among others.* Compared with peers of the same socioeconomic status who identify as heterosexual and nontransgender, LGBT individuals are more likely to face barriers accessing appropriate medical care, which may create or increase existing disparities.* Moreover, it was found that, despite LGBT individuals sharing with the rest of society the full range of health risks, these individuals share a profound and poorly understood set of additional health risks, due primarily to social stigma.*

The authors of the JAMA study found that, of 132 medical schools surveyed, the median reported time dedicated to teaching LGBT-related content in the entire curriculum was five hours, and 48 schools reported zero hours taught during preclinical and/or clinical years. In particular, osteopathic schools surveyed fared even worse, dedicating zero mean clinical hours to teaching LGBT-related content, compared to two mean clinical hours at allopathic schools.

The Association of American Medical Colleges (AAMC) has recommended that medical schools make necessary changes to curricula to ensure that students master the knowledge, skills and attitudes necessary to provide excellent, complete care for LGBT patients by providing comprehensive content addressing specific health care needs of LGBT patients.

The discussions [on these topics] that began [at DMU] last year are an important step, but there is progress yet to be made.

These discussions, in addition to curriculum changes, must continue – not as a means to change students’ ideological, spiritual, personal or cultural beliefs regarding LGBT individuals, but rather to ensure that students gain the communication skills necessary to address issues of sexual orientation and gender identity (issues we will most definitely face in clinic, whether we like it or not). These conversations are a matter of health literacy and are a crucial element in our training as future health care providers.

This past October, LGBT individuals across the country celebrated National Coming Out Day with the goal of sharing the message with friends, co-workers, colleagues and families that LGBT individuals are just that, individuals. They are people with whom we interact on a daily basis, people we already know, like and respect, who happen to be gay, lesbian, bisexual or transgender. Moreover, with roughly eight million Americans identifying as members of the LGBT communities and more than 19 million Americans reporting they engage in same-sex sexual practices, these individuals also are our future patients (the Williams Institute, 2011).

It is my hope that, as a University, we can continue to ponder and discuss ways to lay our own biases aside in order to provide excellent, evidence-based comprehensive health care for our future patients, no matter who walks through our door.

Will Narracci completed his second year in DMU’s osteopathic medical program in May; he’s also pursuing his master of public health degree. He is past president of the DMU American Medical Association/Iowa Medical Society and past co-president of the DMU Gay Straight Alliance. This article is excerpted from the fall 2011 issue of The Innominate, a publication by DMU students.

*Obedin-Maliver, J.; Goldsmith, E.S.; Stewart, L.; White, W.; Tran, E.; Brenman, S.; Wells, M.; Fetterman, D.M.; Garcia, G.; Lunn, M.R. (2011). Lesbian, gay, bisexual and transgender-related content in undergraduate medical education. Journal of the American Medical Association, 306:9, 971-977.

Medical professionals who understand the diverse and unique health care needs of LGBTQ patients are key to competent, compassionate health care.
isn’t that the goal?

Shai Feingold, D.O.’11, acknowledges he heard “inappropriate and even hurtful” anti-gay comments by fellow students and some faculty when he was at DMU. He points out the lack of education both in medical school and during his residency on caring for patients who identify as lesbian, gay, bisexual or transgender and those questioning their sexual orientation or gender identity (LGBTQ populations). More important than any of that, though, is the primary reason he and his colleagues chose to pursue health care careers.

“We’re all here to serve patients; it doesn’t matter what their orientation is,” he says.

That said, Feingold and others note the importance of understanding the diverse and unique health care needs of LGBTQ patients. That’s a challenge for many health care professionals: A recent report of the Institute of Medicine noted that a scarcity of research on LGBTQ populations “yields an incomplete picture” of their health status and needs, “which is further fragmented by the tendency to treat sexual and gender minorities as a single homogeneous group.”

Adding to that challenge is the “stigma experienced by gender and sexual minorities can make them reluctant to disclose their orientation,” the report stated.

“That [stigma] affects their health care, their ability to get health insurance and their mental health,” Feingold says. “It affects their ability to establish healthy relationships, so they may engage in risky behaviors.”

That can compound the health problems of LGBTQ individuals.

“Among these populations is a high risk of drug addiction, alcohol abuse, depression and suicide. You have to find out that history,” says Andrew Adair, D.O.’98, FACOS, a physician with Henry Ford Macomb Family Medicine in Chesterfield, MI, and president of the Michigan Association of Osteopathic Family Physicians. “You have to look at the situation from each patient’s point of view. If they had a rough time coming out, they’ve had trust issues.”

Adair seeks to establish the trust of his patients, who include LGBTQ individuals, by combining compassion and honesty.

“When they say, ‘I’m X, Y or Z,’ I don’t blink,” he says. “I ask frank questions about sexual partners: ‘Do you have sex with men, women or both?’ I don’t care if they’ve been married for 20 years. If you don’t ask the questions, you won’t know the answers.

“Patients want honesty,” Adair adds. “I tell them, ‘I want to help you, but I need your help in guiding your health care.’”

A GOOD START: A GOOD FORM

Asking about a patient’s sexual orientation and sexual behavior isn’t easy for many physicians. They may feel uncomfortable or too pressed for time to ask open-ended questions about those topics. They may simply assume their patients are heterosexual. And since patients don’t want to face discrimination or be judged, their sexuality may never be discussed, says Roberta Wattleworth, D.O.’81, M.H.A.’99, M.P.H.’04, FACOFP, FNAOME, professor of family medicine.

“I’ve practiced in four states and seldom does it happen that patients share revealing, intimate details on the first visit,” she told approximately 60 DMU students who attended her presentation on how to take a sexual health history. “I try to give off the impression I’m receptive and accepting.”

Wattleworth says the patient history form is a good way to demonstrate openness and obtain
patient information. She suggests it include options for patients to indicate their gender, the gender/s of their current and past sexual partner/s, the form/s of sexual activity in which they participate and their exposure to and concerns about violence and abuse.

“The fact you have those questions on your form opens the dialogue for people to feel comfortable in discussing things with you,” Wattleworth told the students. She also emphasized that other clinicians in the practice must embrace those questions.

“If you’re going to share the form and somebody in the practice is not comfortable discussing those issues, what are you going to do about it?” she queried. “You’ve got to decide you’re going to be unified in caring for these populations, because you can’t have one clinician alienating patients so they don’t come back.”

Wattleworth says physicians also must advocate for their patients. With LGBT patients, that may involve communicating with health insurance carriers when gender-related procedures – such as hormone replacement therapy, sexual reassignment surgery and the counseling required beforehand – are medically necessary.

Health care providers may need to advocate for patients within their families, too. Wattleworth shared with students her experience with a young male who came to her after being diagnosed as HIV-positive.

“He burst into tears and said, ‘I’m scared,’” she recalled. She offered to go with him to talk with his parents. “I could see the color drain from his mother’s face. The father stood up and started yelling. I said, ‘Sir, your son needs your support, not your condemnation, so please sit down and listen.’

“It was a difficult, difficult conversation, but that was a time to advocate for that young man,” she added.

EDUCATED AND ‘OUT’ AS LGBTQ-FRIENDLY

Joe Freund, M.D., came out as a gay male at age 40 but admits he’d had “very little education on providing care to LGBTQ patients.” The Des Moines physician, who spoke on gender and sexual orientation issues during a recent campus panel discussion, decided to join the Gay and Lesbian Medical Association (GLMA), which works to ensure equality in health care for LGBT individuals and health care professionals. GLMA provides resources for patients, including a provider directory and suggested issues to discuss with one’s physician, and resources for providers, such as online continuing education and annual scientific meetings.

Affiliating with such organizations lets LGBTQ patients know whether a provider is accepting as well as informed about their health care needs. Andrew Adair, the DMU graduate, joined the LGBT-friendly health provider list maintained by Affirmations, a multi-service nonprofit organization near Detroit that serves persons of all sexual orientations and gender identities. To be added to the directory, Adair agreed to uphold the organization’s “community standards of practice,” which include maintaining an inclusive, nondiscriminatory environment for LGBTQ patients, having a “basic familiarity” with their health care issues, and including in their care those patients’ domestic partners and/or other chosen family members the same as for heterosexual patients.

“Once these individuals find out a physician is friendly, they come to that physician in flocks,” Adair says. “If you’ve got a patient whom you don’t like, for whatever reason, you can’t provide effective care. If you can’t deal with this population, you’d better make it really well known.”

John Carstensen, M.D., a GLMA member and internal medicine physician with Iowa Health in Des Moines, says letting patients know he’s accepting of LGBTQ patients, whether through conversations or printed materials in his waiting room, fosters the trust needed for effective health care. So does understanding the diverse needs across LGBTQ populations.

“The care they need depends on whether the patient is a gay male, a gay female, a transgender person who either has or has not undergone surgery, etc.,” says Carstensen, who has participated in campus discussions hosted by DMU’s Gay Straight Alliance. “Physicians need to be comfortable in asking those questions and researching solutions based on the patients’ needs.”

Equipping health care students to provide competent, respectful care for all patients, including LGBTQ populations, is both a challenge and an imperative for institutions like DMU.

As a nation founded on principles of democracy, freedom and inalienable rights, America remains unsettled in its acceptance of individuals who are not heterosexual – often referred to as lesbian, gay, bisexual, transgender or questioning their sexual orientation or gender identity, or LGBTQ.

In May, President Barack Obama announced his support of same-sex marriage, and a Washington Post/ABC News poll reported that more than half of Americans say same-sex marriage should be legal. Yet 31 states have passed amendments aimed at banning it.

Teenage gay and lesbian roles are popping up in popular television programs like “Pretty Little Liars” and “Glee.” Yet in April, gay Iowa 14-year-old Kenneth Weishuhn joined the statistic of teens who have committed suicide after being bullied. Even at Des Moines University, where students train for professions focused on caring for all people, anti-LGBTQ actions have occurred.

“I think some of our students, depending on their backgrounds, may struggle with accepting and understanding gay and lesbian individuals,” says Roberta Wattleworth, D.O.’81, M.H.A.’99, M.P.H.’04, FACOFP, FNAOME, professor of family medicine. “But if they don’t think they’ll have gay and lesbian patients, their heads are in the sand.”

The inevitable diversity among patients and the demands of providing high-quality health care require that DMU students feel safe and accepted on campus, on rotations and in residency, and that they also know how to create safe environments as health care professionals.

“Regardless of sexual orientation, race, culture and other factors, we’re all very different in our life experience,” says Jeffrey Means, Ph.D., chair of behavioral medicine at DMU. “It’s important that we teach each student how to relate to and treat each patient as an individual. That’s patient-centered care.”

Embracing diversity in its many forms and preparing students for a diverse world, says Daryl Smith, Ph.D., are not about being politically correct or “being nice.” A professor of education and psychology at the Claremont Graduate University in Claremont, CA, Smith was invited to DMU by student services staff last year to lead a campus-wide discussion about diversity and inclusiveness.

“Making diversity central to the mission of higher education is about excellence,” she said during her visit. “We have to have the capacity for difficult dialogues. Our future as a society depends on our ability to talk to each other.”

A diverse workforce of health care leaders, providers, faculty and researchers is needed to serve increasingly diverse patient populations and reduce health care disparities, Smith said. Preparing students to be that workforce, including interacting with LGBTQ patients and colleagues, is the challenge. What happens, say, when a medical provider has no idea how to counsel a teen patient who thinks he is gay? Or when that provider’s religious beliefs oppose a patient’s sexual orientation? How can medical schools address these gaps and biases so students may go on to become excellent health care providers and leaders?

“What’s really important is a good curriculum that differentiates ethics and morals,” says Will Narracci, D.O.’14, M.P.H.’14, who served as co-president in 2011-2012 of DMU’s Gay Straight Alliance. “Morality encompasses one’s personal beliefs; ethics are standards of the profession. You can have your personal beliefs, but you have to uphold professional ethics in caring for patients.”

To improve visibility and support of LGBTQ students, employees and campus visitors, DMU implemented a “Safe Zone” program. Students and employees can opt to participate in training that equips them to be allies for LGBTQ individuals.

“While other minority individuals can often identify role models and mentors, the invisibility of sexual orientation makes it difficult for LGBT members of the DMU community to ascertain where they can safely turn for support and information,” says DMU President Angela Walker Franklin, Ph.D. “Safe Zone training is an integral way to create an inclusive campus environment and to train future health care professionals.”

With last year’s change to DMU’s mission and vision statements – an effort President Franklin also led – “embracing a culture of diversity that accepts and respects the unique characteristics of each individual” is now among the University’s institutional values. In addition, last year a faculty/student committee on professionalism revised DMU’s honor code into a Professional Integrity Code that includes inclusiveness as a key tenet.

“With diversity in our mission statement, as a faculty member I feel justified in asking questions and taking care of related issues for students,” says Julia Moffitt, Ph.D., associate professor of physiology and pharmacology.

The revised mission statement also underlines the need to embed diversity throughout the curriculum.

“To develop cultural competency among students, we must expose them to differences and scenarios in which diversity is there,” Moffitt notes. “Why does every heart attack case presented in class have to be a white male in his 60s?”

A CASE FOR DIFFERENT CASES

Diversifying patients in cases presented in classes, in the simulation laboratory and in the Standardized Performance Assessment Laboratory (SPAL) is one way to reflect society’s variations in sexual orientation, race, ethnicity, language, cultural background, socioeconomic status and more. For example, Matthew Henry, Ph.D., chair of physiology and pharmacology, changed an infertility case involving a husband and wife to one in which the couple were two lesbians. Before he presented the case, however, he shared it with a colleague for feedback.

“I wanted to make sure I wasn’t going to speak in a biased way – not intentionally, but in a way that might offend someone in the class,” Henry says. “As a department chair, I want an environment where it’s safe for students and faculty to ask those questions.”

Diversifying cases exposes students to different people and situations and helps prepare them to be professional and nonjudgmental toward patients and colleagues. In an online course she teaches in DMU’s post-professional doctor of physical therapy program, Kandace Davis, D.P.T.’03, M.S.P.T.’95, includes a scenario in which students imagine they’re directors of a mid-sized clinic where a valued colleague confides he/she is gay/lesbian but does not feel the clinic is LGBT-friendly.

“More than 80 percent of the students typically answer they’d never considered the issue before,” says Davis, who practices in Gothenburg, NE. “That sparks dialogue, awareness and sensitivity.”

The University’s new Center for the Improvement of Teaching and Learning (CITL) will offer resources for helping faculty incorporate diversity and inclusiveness in their courses. Annie Daniel, Ph.D., who became CITL director on May 15, says she’ll use the data-driven faculty development program she implemented in Tulane University’s School of Medicine in New Orleans, where she completely rebuilt its office of medical education after Hurricane Katrina. That program has helped faculty improve their pedagogical skills and engage in professional development and medical education research.

“We have to have an adequate course evaluation process for students and needs assessment among faculty, so we can determine what faculty need in developing curriculum,” she says.

STUDENTS DRIVE CHANGE

Faculty praise the students who seek exposure to different populations, from going on global health service trips to visiting Des Moines’ homeless camps. This spring, the International Medicine Club seized the idea of its advisor, Alisdair “Rod” Philp, Ph.D., to organize a series of events designed to improve student awareness and competency in dealing with different cultures; recent events included a visit to a local mosque, a speaker on the culture and health issues of Native Americans, and a panel of students and providers on LGBTQ issues in health care. Osteopathic medical students who attend 10 or more of these events by the end of their second year will receive a cultural awareness endorsement on their dean’s letter of recommendation.

Faculty also praise members of the Gay Straight Alliance (GSA) for their role in driving difficult yet critical discussions over the past year. GSA member Angela Knoblauch, D.O.’14, wants to make sure those conversations continue.

“Sometimes it does take students at the grassroots level to make change occur,” she says. “I think we can make a big difference. It’s all about preparing people to be better health care providers.”

Regardless of one’s personal views, attitudes against non-heterosexuals are harmful to health care, both for patients and the profession.

As a nation founded on principles of democracy, freedom and inalienable rights, America remains unsettled in its acceptance of individuals who are not heterosexual – often referred to as lesbian, gay, bisexual, transgender or questioning their sexual orientation or gender identity, or LGBTQ. In May, President Barack Obama announced his support of same-sex marriage, and a Washington Post/ABC News poll reported that more than half of Americans say same-sex marriage should be legal. Yet 31 states have passed amendments aimed at banning it.

Teenage gay and lesbian roles are popping up in popular television programs like “Pretty Little Liars” and “Glee.” Yet in April, gay Iowa 14-year-old Kenneth Weishuhn joined the statistic of teens who have committed suicide after being bullied. Even at Des Moines University, where students train for professions focused on caring for all people, anti-LGBTQ actions have occurred.

“I think some of our students, depending on their backgrounds, may struggle with accepting and understanding gay and lesbian individuals,” says Roberta Wattleworth, D.O.’81, M.H.A.’99, M.P.H.’04, FACOFP, FNAOME, professor of family medicine. “But if they don’t think they’ll have gay and lesbian patients, their heads are in the sand.”

The inevitable diversity among patients and the demands of providing high-quality health care require that DMU students feel safe and accepted on campus, on rotations and in residency, and that they also know how to create safe environments as health care professionals.

“Regardless of sexual orientation, race, culture and other factors, we’re all very different in our life experience,” says Jeffrey Means, Ph.D., chair of behavioral medicine at DMU. “It’s important that we teach each student how to relate to and treat each patient as an individual. That’s patient-centered care.”

Des Moines University recently added the concepts of diversity and inclusiveness to its mission and values, and not because it was the “Iowa nice” thing to do: At a time when diversity among Americans – in terms of race, ethnicity, socioeconomic status and many other factors – has never been greater, it’s imperative the University prepare future health professionals who can provide effective, culturally competentcare to all. But what does “cultural competency” entail, and how can students achieve it?

DMU Magazine will explore those questions with this periodic series, “Caring for the Spectrum of Difference.” In this issue, we consider health care issues and education as they relate to lesbian, gay, bisexual, transgender and questioning populations.

“At DMU, we are working to create opportunities to have difficult dialogues to help us identify our biases and stretch our perspectives,” says Lynn Martin, Ph.D., director of educational support services.

In health care, cultural competency means providers and organizations are able to treat patients of different backgrounds according to their unique cultural needs, beliefs, customs, values and risk factors (Office of Minority Health, U.S. Department of Health and Human Services).

Fostering cultural competency among students is also an expectation of the Higher Learning Commission (HLC), the independent organization that accredits U.S. colleges and universities. In its scheduled review earlier this year of DMU’s accreditation status, HLC noted the University failed to address diversity in its previous mission and vision statements. Both have been revised to include the concept as a priority. (In June, HLC granted DMU continued accreditation, with the next scheduled evaluation in 2021-2022.)

In the past year, the DMU community has begun frank discussions on truly living its mission and vision by embracing diversity and fostering cultural competency in classrooms, in clinical experiences and across campus. The verdict: Progress has been made, there’s still much work to be done, and the job will never be over.

Throughout this and other installments in our “Caring for the Spectrum of Difference” series, we invite you to share your perspectives, experiences, advice and questions on the complex topic of cultural competency.

In this series:

Gender minorities and medicine

Regardless of one’s personal views, attitudes against non-heterosexuals are harmful to health care, both for patients and the profession. As a nation founded on principles of democracy, freedom and inalienable rights, America remains unsettled in its acceptance of individuals who are not heterosexual – often referred to as lesbian, gay, bisexual, transgender or questioning their…

Achieving intolerance for intolerance

Equipping health care students to provide competent, respectful care for all patients, including lesbian, gay, bisexual, transsexual and questioning populations, is both a challenge and an imperative for institutions like DMU. It’s not about being “nice”; it’s a critical aspect of educational and professional excellence.

Keeping patient care as priority one

Medical professionals who understand the diverse and unique health care needs of LGBTQ patients are key to competent, compassionate health care. Lack of that understanding as well as the stigma and disparities experienced by many non-heterosexuals can compound these populations’ health problems.

From a student’s perspective: Outing anti-gay biases in health care

“LGBT individuals are individuals,” states Will Narracci, D.O.’14, M.P.H.’14. “They are people with whom we interact on a daily basis, people we already know, like and respect, who happen to be gay, lesbian, bisexual or transgender.”