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

Caring for the Spectrum of Difference

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moves on to another question, but you see through the body language of the patient that she has become emotionally withdrawn.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

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