Prescription for disaster

How many times have you had to deal with a doctor asking you what form of birth control you use?

When I was younger, I used to blush with embarrassment. A little older, I would say, cryptically, “I don’t have that kind of sex.” Later I enjoyed being even more provocative.

“I don’t use birth control,” I would say with deadpan delivery.

“Well, that’s a little risky, isn’t it?” was the predictable response.

“Not when you’re fucking girls,” is what I would have liked to have said. But instead, I bravely said and continue to say “Uh, I’m a lesbian.” I used to get a rush from saying it.

Would my doctor be shocked? Would she be less comfortable sticking my feet in oven mits and doing the old pap thing once a year? Would she ask me whether I routinely examined my breasts rather than examining them herself out of some fear that I would misconstrue this mammary handling?

“GLBs often feel uncomfortable disclosing their sexual orientation to physicians,” says Dr Allan Peterkin in a new study guide he’s prepared for medical students and doctors. He’s an assistant professor of psychiatry and family medicine at the University Of Toronto. “They often fear that if they come out to their doctors they will be denied care, treated in a rejecting manner, or that doctors will over/under emphasize sexual orientation, moralize, attempt to change them or violate confidentiality.”

These types of questions and fears are neither unfounded nor uncommon. As Peterkin writes: “Physicians often feel uncomfortable dealing with GLB patients.”

While the discomfort cuts both ways, it is gay and lesbian patients themselves who suffer for it. Rather than risk encountering a homophobic reaction, many homos put themselves at significantly greater risk by undergoing unnecessary or inappropriate testing or treatment, or by not making their health care needs explicit.

Many of us have experienced overt discrimination or are simply reluctant to make our sexual orientation known. For example, a friend of mine, a young lesbian struggling with her sexuality, sought medical help for what was ultimately diagnosed as pelvic inflammatory disease. As is common in such cases, the doctor insisted that she was probably pregnant. Rather than out herself, my friend went ahead and subjected herself to unnecessary pregnancy testing.

A woman in an abusive relationship may be particularly reticent to admit to abuse in a relationship society already deems as perverse. Where the evidence of abuse is undeniable, she may well allow a doctor to assume her partner is male and be given inappropriate referrals.

On the other hand, where bruises and scars are the outcome of consensual, sexual activity, her doctor might be led to assume abuse where none exists.

In order to avoid these kinds of situations, it is vital to be out to your doctor.

“I’ve actually emphasized my orientation with doctors,” says U of T professor Maureen FitzGerald, “whatever their reaction.”

FitzGerald and her partner co-parent their son, but it can be difficult to get the relationship acknowledged. Both women make their relationship to their son and each other publicly visible in order to ensure that they are both consulted and involved in decisions about his health care.

Maureen’s attitude is that doctors should be forced to deal with alternate realities and confront their own stereotypes and assumptions.

Depending on the situation, though, being out is easier said than done.

With a family doctor, there are various levels of coming out. Revealing one’s gay identity might be the easiest part. Some gay men, in particular, may be more uncomfortable revealing the number of sex partners they’ve had. Or their sexual practices. How comfortable would you be confessing to a dildo related injury? But without this information, doctors may not be asking the right questions.

In situations of emergency care, when personal details are often the most important, we are often not in the position of being able to choose a tolerant person to provide for our medical care.

“I would rather come out at Hockey Night In Canada than in any hospital in this country,” filmmaker Lynne Fernie says. In hospital “you are seen by any number of different people and you don’t know what each of them is thinking when they see Great Big Lesbian written all over your chart. Imagine being in St Mike’s and having someone walking around thinking sinful things about you while you’re lying there trying to recover?”

For men, hospitals can offer up creepy little homophobes examining your testicles. Are you really going to out yourself while he holds the potential for your next 60 orgasms in his hand?

Not disclosing your sexual orientation in hospital means not only the potential of inappropriate care, but taking the risk that your same-sex partner will be denied recognition and access in the case of serious or fatal conditions.

But proper communication is not the sole responsibility of gay and lesbian patients. If doctors and medical personnel were taught not to assume heterosexuality and further, to be sensitive and empathic to the needs of their lesbian and gay clients, there would be greater room for dialogue.

Most medical schools and health care training facilities in Canada, though, have historically had poor track records of offering any specific education surrounding the needs of lesbian and gay patients. This formal neglect is hardly surprising, but it does places serious limits on the degree to which health care practitioners are aware and informed of and receptive and empathic to the needs of the community.

Slowly, though, things are changing in some medical schools.

McMaster University in Hamilton has become well-known in North America for producing doctors who are more holistic in their approach to patient care, an approach that better serves gay and lesbian patients. Alison Howatt, a recent graduate from McMaster, says she went through several workshops that touched on gay and lesbian issues. When meeting any patient for the first time, she uses inclusive language like “Do you have a partner?” It seems simple, but it makes it easier for patients to be honest.

But much medical training that is labelled “inclusive,” is not specifically gay and lesbian.

“A lot of people mistake HIV care for gay and lesbian health care,” says Dr Richard Montoro of the McGill University Sexual Identity Centre. “Lesbians are often left out. And gay men who don’t have HIV issues are left out.”

To fill in the gaps, Dr Peterkin has compiled his study guide, Caring For Gay And Lesbian Patients, in collaboration with the Canadian Psychiatric Association. It’s intended to assist practitioners and students in identifying their attitudes and approaches toward homosexual patients.

The guide is designed to alert students from a wide variety of disciplinary backgrounds – nursing, social work, medicine, psychiatry, psychology, physio and occupational therapy – as to how their homophobia limits their ability to offer effective and empathic treatment.

The initiative came about when medical students in a second year course on human sexuality at the University Of Ottawa asked Peterkin and his colleagues for specific training on working with lesbian and gay patients. Peterkin put together a panel of “experts” to candidly tell their coming out stories.

Rather than focussing on how they have been mistreated or mishandled within the health care system, these individuals discuss homophobia – both internalized and externalized – and how this has affected their lives. One gay man grew up in a rural setting. One gay man was married and came out in mid-life. One is a lesbian mother and the other is a mother of gay children.

(The guide does neglect to consider is that each of the narratives offered is that of a white Canadian. Race, class, gender and relationship status obviously interact with orientation to produce a much more complicated picture.)

What is made clear, is that gay and lesbian development cannot be measured according to the heterosexist criteria upon which most health care practice is based. Most importantly, perhaps, the guide asks medical students to recognize and assess the extent of their own homophobia.

On a larger scale, a medical centre in Montreal may provide a model for better health care for the gay and lesbian community.

The McGill University Sexual Identity Centre (MUSIC) opened in September 1999 as an outpatient psychiatry clinic for gay men, lesbians, those questioning their sexuality and their family and friends. The clinic screens about four patients a week, following through with some of them, referring others to an appropriate family physician. It effectively puts into practice the kind of guidelines Peterkin would like to see employed in mainstream health services.

“We’re not saying gay patients should only see gay psychiatrists,” says Dr Montoro, the clinic’s founder. “Rather, someone who is gay informed. It’s in entry point into the system rather than relying on word of mouth so you can know where to go.”

Appropriate health care will only be possible through an exchange of information. Most of us would rather have our doctors ask us. But sometimes we’ve got to be willingly to educate them when they don’t understand.

The Rainbow Triangle Alumni Association of the University Of Toronto is screening the video Caring For Lesbian And Gay Parents in Room 140 of University College on Dec 6 at 7pm.

MUSIC can be reached at McGill University Sexual Identity Centre, Montreal General Hospital, (514) 937-6011 ex 2371.