By Harvey J. Makadon
http://content.nejm.org/cgi/content/short/354/9/895

The New England Journal of Medicine
Volume 354(9), 2 March 2006, pp 895-897

Improving Health Care for the Lesbian and Gay Communities
[Perspective]

Makadon, Harvey J.

Dr. Makadon is director of education and professional training at
the Fenway Institute, Fenway Community Health; a staff physician
in general medicine and primary care at Beth Israel Deaconess
Medical Center; and an associate professor of medicine at Harvard
Medical School - all in Boston.

Outline

REFERENCES

Graphics

Figure 1

   On my 40th birthday, I made two important decisions regarding
my health: I would finally see a physician on a routine basis,
and I would be frank with my newly chosen doctor about being gay.

This revelation might seem to have come late in life, but for me
it was a major breakthrough.

Although this physician had been recommended to me by colleagues,
I was disappointed by the lack of discussion following my
emotionally difficult statement about my sexual orientation.

He did not discuss my sexual history or recommend that I be
tested for HIV, nor did we discuss the need for hepatitis A or B
immunizations.

   More recently, I had a different but similarly off-putting
interaction with the health care system.

At the registration desk for a physician's practice at a nearby
hospital, I was asked, rather publicly, whether I was married or
single.

When I replied that I had a partner, a second office worker
sitting next to the registration clerk leaned over and loudly
exclaimed, "He's single."

Even as I tried to see the humor in this exchange, I remained
disturbed by the ease with which a significant relationship could
be dismissed, as well as by the chilling effect it had on my
eagerness to be seen as a patient at this practice.

   From my perspective as a clinician and teacher, these
experiences were disappointing but not surprising.

There is little formal education about sexual minority groups
included in medical training.

As a result, otherwise knowledgeable providers are often
uninformed about basic issues that are essential to providing
high-quality care to this population.

Indeed, when I discussed my dismay about the first encounter with
one of my colleagues, she asked why I thought my physician should
have discussed hepatitis A immunization - although since 1996 the
Centers for Disease Control and Prevention (CDC) has formally
recommended such preventive care in gay men.

Would greater attention, during medical school, training, or
continuing medical education, to gay men's health care have made
such immunization more routine?

   Such educational gaps persist despite the numerous reports
indicating a need for greater attention to the health of the
lesbian and gay communities.

A 1999 report from the Institute of Medicine entitled "Lesbian
Health: Current Assessment and Directions for the Future"
evaluated the strength of the existing research on the physical
and mental health of lesbians.

It reported a lack of lesbian-specific research and suggested
that "misconceptions about risk . . .  can negatively affect both
the ability of lesbians to seek health care and access to
treatment itself."

Similarly, "Healthy People 2010," a 10-year plan developed by the
Department of Health and Human Services in 2000, identified
lesbian and gay Americans as one of six U.S. population groups
affected by health disparities.

   Despite such alerts, the medical resources that primary care
providers commonly use in making treatment decisions pay little
or no attention to issues of care for homosexuals and
bisexuals.

As an example, although UpToDate, an online resource for clinical
information, has a comprehensive section on the gynecologic care
of lesbians, it has no section presenting an organized approach
to the care of gay men.

The most recent edition of Branch's primary care textbook The
Office Practice of Medicine, published in 2003, does not even
mention the words "gay" and "lesbian" in its Table ofcontents or
index.

Providers need easy access to information on how best to provide
high-quality care to the lesbian and gay communities.

No physician can know everything, but our routine sources of
information should cover issues relevant to the care of this
population.

   Increasing the profession's awareness of the core medical
issues for gay men and lesbians is the first step.

Today, we are seeing a growing epidemic of sexually transmitted
diseases among gay men, with a resurgence of gonorrhea, syphilis,
and chlamydia, in addition to conditions such as lymphogranuloma
venereum, that were previously less common.[1]

All these diseases are easy to diagnose and treat, but if newer
trends in prevalence are not acknowledged in medical education,
physicians are unlikely to pay appropriate attention to necessary
behavioral change and medical treatment when seeing patients in
clinical settings.

   Providers also need to be aware of related contributory and
potentially hazardous trends, such as the current epidemic of
crystal methamphetamine use, in order to effectively address
these issues with patients.

The CDC has suggested that HIV prevention also be addressed
routinely during primary care visits in an effort to reach
populations in which the epidemic is growing.[2]

Nevertheless, studies have consistently shown a considerable
disparity between the attention paid to assessing the risk of HIV
infection and other sexually transmitted diseases and that paid
to assessing cardiovascular risk in office sessions.[3]

In both cases, changing potentially harmful behavior remains a
challenge, but addressing the need for change is the first
important step.

What message do we as physicians send to our patients, gay or
straight, when we ignore safety issues related to sexual
behavior?

   There are similar lacunae in most health care professionals'
knowledge about appropriate cancer-prevention strategies for
lesbians and gay men.

It is recommended that cervical examinations be performed in
lesbians according to the routine guidelines for all women, since
studies of lesbians' sexual behavior reveal both great
variability and substantial rates of sex with men, with the
attendant risks of infection with the human papillomavirus (HPV)
and the evolution of cervical carcinoma.[4]

Yet physicians frequently assume that lesbians have low or no
risk of HPV infection and fail to perform both Papanicolaou (Pap)
smears and pelvic examinations.

   Similarly, there is a growing body of literature on the
appropriateness of screening for anal dysplasia in men who have
sex with men as a way of preventing the development of anal
carcinoma.

But there has been little effort to disseminate this information
formally or to put systems in place to make the anal Pap smear
part of clinical practice, at least for patients with HIV
infection, who have the highest risk of anal carcinoma.

   Physicians can also play a critical part in helping lesbian
and gay patients to confront questions or confusion about their
sexuality - and about "coming out" to themselves and others.

In this respect, the physician's role is no different from that
of the primary care provider who assesses issues such as
difficulty with relationships or domestic abuse and subsequently
makes referrals for counseling.

Whether the patient is an adolescent (who may be at risk for a
suicide attempt[5]) or a middle-aged man or woman just beginning
to identify as a homosexual after years of living a heterosexual
life (who may feel isolated from family and friends), physicians
should be aware of the issues that commonly arise in these
circumstances.

Nevertheless, guidelines for clinical practice can be very
simple: ask the appropriate questions and be open and
nonjudgmental about the answers.

Few patients expect their providers to be expert on all aspects
of gay and lesbian life.

But it is important that providers inquire about life situations,
be concerned about family and other important relationships,
understand support systems, and make appropriate referrals for
counseling and support when necessary.

   Finally, we should consider how our practices could create an
environment welcoming to homosexuals and bisexuals, helping to
eliminate real or perceived barriers to care.

The 2000 U.S. Census showed that this group makes up 5 to 7
percent of the population in major urban centers, and it
identified at least one household headed by a same-sex couple in
more than 99 percent of U.S. counties (see map [Figure 1]).

If all health care providers reworded their forms to include
lesbian and gay patients (asking, for instance, for the names of
a child's parents rather than the mother and father), armed
themselves with information about relevant resources available in
the community, and ensured that all their staff were educated
about relevant gay and lesbian issues, it would make a big
difference.

   
     Figure 1. Same-Sex Couples in the United States.

               Each star represents 250 households headed by a
               same-sex couple, as reported in the 2000
               U.S. Census.

               The total number of such households was 594,391
               in 2000.

               Map courtesy of Judith Bradford, Ph.D., and
               Kristen Barrett, Ph.D., Survey and Evaluation
               Research Laboratory, Virginia Commonwealth
               University.
   
 

   Acting as individual clinicians, we may not be able to change
national health care policy.

Yet we must all be aware that we are most likely seeing gay and
lesbian patients, as well as patients who, although they do not
consider themselves to be homosexual, are exploring their
sexuality with same-sex partners.

At the very least, we can adapt our own practices, and we can
work with our medical schools and professional organizations to
incorporate more information, at all educational levels, about
the care of this population.

We can also help our patients take steps toward leading open and
healthy lives.

REFERENCES
1. Ciesielski CA.
  Sexually transmitted diseases in men who have sex with men:
  an epidemiologic review.
  Curr Infect Dis Rep 2003;5:145-52.

2. Incorporating HIV prevention into the medical care of persons
  living with HIV: recommendations of CDC, the Health Resources
  and Services Administration, the National Institutes of
  Health, and the HIV Medicine Association of the Infectious
  Diseases Society of America.
  MMWR Recomm Rep 2003;52(RR-12):1-24.
  [Erratum, MMWR Recomm Rep 2004;53:744.]

3. HIV prevention practices of primary-care physicians -
  United States, 1992.
  MMWR Morb Mortal Wkly Rep 1994;42:988-92.

4. White J.
  Primary care of lesbians.
  In: Noble J, ed.
  Textbook of primary care medicine. 3rd ed.
  St. Louis: Mosby, 2001:336-9.

5. Garofalo R, Wolf RC, Wissow LS, Woods ER, Goodman E.
  Sexual orientation and risk of suicide attempts among a
  representative sample of youth.
  Arch Pediatr Adolesc Med 1999;153:487-93.
  Bibliographic Links Library Holdings

http://content.nejm.org/cgi/content/short/354/9/895
By Harvey J. Makadon