Lesbians fly under the medical gaydar

It's always a good time to talk about sex
with your gay patients

By Bonnie Bowman

If this isn't already part of the routine list of questions you ask all of your patients, it should be, says Montreal family doctor and public health physician Dr Marc Steben.

"This is a neutral question anddoesn't impose a judgment," he says. "It certainly opens the door for the patient."More specifically, it opens the closet door for gay, lesbian and bisexual patients who may be fearful of divulging their sexual identity because of discrimination they have suffered in the past. They may also be put off by the 'heterocentric' language and attitudes in the medical community. It also opens doors for physicians who may be feeling ill-equipped to bring up the topic of sexual orientation; many just assume their patients are heterosexual unless they're told otherwise.

"AM I A HETEROCENTRIC DOC?"
Dr Steben, who works at Quebec's Public Health Institute, as well as the STD unit, vulvovaginal clinic and gyne-oncology department at the Centre hospitalier de l'UniversitÄ de MontrÄal, runs workshops on this very issue, including one at the recent Society of Obstetricians and Gynaecologists of Canada meeting in June. He concedes it's a challenge for both parties and avoidance is often the preferred route. "Sometimes when we've had discussions with the gay community, they say physicians aren't interested,"he says.

But feedback from his workshops, and recent surveys of GPs in Canada and abroad, suggest there is increasing interest among physicians in learning more about this patient population. "Years ago, we were never provided information about special issues regarding homosexuality," says Dr Steben. "I think we were forced to ask heterocentric questions."

Dr Allan Peterkin, associate professor of psychiatry and family medicine at the University of Toronto and staff psychiatrist at Mount Sinai Hospital, agrees. Dr Peterkin treats a large number of gay, lesbian and transgendered patients and has tackled many of their health issues in his comprehensive book Caring for Lesbian and Gay People: A Clinical Guide, co-written with Dr Cathy Risdon. He says it could be as simple as changing the way you ask a question. "Asking in a direct, open manner normalizes the discussion and sends signals that the doctor is comfortable discussing a person's life in a respectful, holistic way." The words you choose also make a difference. "Patients have said it's difficult to come out to a doctor for the first time when all the messages on intake forms or posters in the waiting room reflect the heterosexual experience," says Dr Peterkin. "And healthcare workers don't always use inclusive language, such as asking about a wife rather than a partner or a spouse."

NO LONGER A DISEASE
This doesn't necessarily translate into physician homophobia. "Homophobia may be less of a concern nowadays, but it was certainly a big concern before, when homosexuality was considered a disease," says Dr Steben noting that it was on the American Psychiatric Association's list of psychiatric disorders until the 1970s. "Most doctors aren't homophobic, most are heterocentric."

Drs Peterkin and Risdon led focus groups and workshops during and after writing their book. They, too, found a high level of positive interest from physicians concerning gay and lesbian health. "I've professionally not encountered much frank homophobia, but rather a lack of understanding of the principles of population health, ie 'I'm the same with all my patients, gay or straight, they all have the same needs'," says Dr Peterkin.

LET'S NOT TALK ABOUT SEX
Awareness about homosexual health concerns has exploded since the HIV epidemic. But Dr Steben points out that while this is a good thing, sometimes the AIDS question can actually cause yet another sort of tunnel vision. As Dr Steben so succinctly puts it: "It's not only about the penis and how they have sex — it's about their life."

"I think men, because of AIDS and STD issues and recent outbreaks, are more visible in the healthcare system than women," says Dr Steben. Lesbians, he points out, are often neglected in their healthcare needs and subsequently put at risk. A prime example is their not receiving regular Pap tests. Straight women, on the other hand, are "held captive by their hormones." "They have to come to the doctor because they need renewals for their oral contraceptives," he notes. "They are caught by the system, so opportunistic screening is easy."

Dr Peterkin agrees. "Regarding assessing sexual risk behaviours, most doctors think to discuss this with gay men, but probably don't do it enough with teenagers, college kids, and lesbian or bisexual women," he says, adding that sexual history taking is only part of the package. Dr Peterkin puts a lot of emphasis on the psychological aspect. "Doctors may forget to explore how being a sexual minority carries its own risks in terms of violence, discrimination, or heterosexism."

He urges physicians to be sensitive to all aspects of their patients' lifestyles. "If you don't know how your patients live, who their families and supports are, or the stressors they face, your care simply falls short."

Once again, lesbians often encounter less understanding from medical professionals than do gay men. "Doctors may embrace stereotypes that one woman in a couple is always dominant or hyper-masculine or that violence does not occur in same sex relationships. Or they may not explore, or take seriously, a woman's wish to have children," Dr Peterkin says, noting some clinics still refuse alternate insemination to female couples.