Canadian Medical Association Journal 1996; 155: 765-770
[en bref]
© 1996 Nancy Robb
Last fall, Ron went to see his family physician about an HIV test. The University of British Columbia medical student was starting a new relationship, and he wanted to take precautions.
But when he mentioned in passing that he was gay, he got more than he bargained for. His physician spent the next 40 minutes expressing his views on religion and homosexuality.
At the time, Ron (not his real name) was experiencing depression related to anxiety over "coming out." His physician "basically said . . . he could not condone my behaviour, but he could still serve me in terms of my medical needs," Ron recalls. "He didn't mention my psychological needs, and I'm not sure he's aware I had any."
His is an extreme case, but other gay or lesbian patients have had negative experiences at the hands of the medical profession. Gay-positive doctors say disenchanted patients often see them after encountering everything from ignorance to homophobia in doctors' offices.
These physicians say part of the solution lies in education. Gay rights and HIV have opened the door to a smattering of workshops and lectures at medical schools, and initiatives such as a postgraduate family medicine curriculum that deals with homosexual issues hold promise. But these physicians believe medical schools must do more to help meet the health care needs of gay and lesbian Canadians.
"Gay invisibility in our curriculum means future doctors may have no idea that gay people have different contributing factors to problems like eating disorders, physical assault, suicide . . . and so on," Dalhousie University medical student Kevin Speight wrote in a recent issue of Mediscan, a CMA-produced publication for medical students. "Because of this, gay patients may be receiving lower-quality health care than they should."
But medical school responsibility extends beyond providing simple facts. As Hamilton family physician Cathy Risdon observes, "for most physicians the challenge is dealing with someone who is not like them . . . and heterosexism just steamrolls over those differences. It's that challenge of being open to those differences and, at the very least, competent in dealing with them."
"One of the number-one health risks for gays and lesbians is fear of seeking medical care," says Risdon, head of the North Hamilton Community Health Centre and a faculty member at McMaster University. She added that some doctors have never considered that some of their patients are gay or lesbian "and wouldn't have the first clue what to do if they found out."
"I went many years without identifying a gay person in my practice," admits Dr. Gary Gibson. "They're there. You just don't see them or you don't make it possible for them to identify themselves to you . . . and if they don't identify, they may not get the medical advice they do need."
Gibson, a family physician in Cambridge, Ont., says that soon after he came out to his colleagues in 1981, at age 40, about 15 of his patients revealed they were gay. Today, one-third of his patients are homosexual.
Gibson, who teaches family medicine at the University of Western Ontario and is active in the College of Family Physicians of Canada, wants more medical education dealing with gay and lesbian issues. He recently drafted a gay and lesbian curriculum for postgraduate family medicine, which was endorsed by the CMA last spring.
He says this "framework" itemizes the knowledge, attitudes and skills that residents should learn, and incorporates them into the four principles of family medicine. "I think attitudes and comfort are the key things in this area given our current state of knowledge and the reality within the medical profession," Gibson says. "I'm not so worried about everybody knowing what to do or how to treat some of these things . . . but I want doctors to see gay and lesbian patients as people and apply the same basic human and professional attitudes and treatment skills to them as they would to any other group."
When Gibson polled family medicine departments about 3 years ago, he found that most medical schools did not have "anything structured around gay and lesbian issues, except to do with HIV disease."
"Linking the two things is not a good idea," he argues. "They're connected, but to attach gay and lesbian issues only to AIDS is unfair. It's like talking about female or male sexuality [only in relation to] ectopic pregnancies or gonorrhea."
He suspects, however, that more schools, especially at the postgraduate level, have placed gay and lesbian issues on the docket since his survey. "The College of Family Physicians started having gay questions on oral exams about 6 or 7 years ago," says Gibson, a past chair of the college's Board of Examiners, "and that has driven some schools' curricula."
At Western, Gibson gives three seminars on HIV and two on gay and lesbian issues to family medicine residents. "My general theme has been to normalize gays and lesbians," says Gibson, who has done workshops at other medical schools. "They look, feel and act and have the same life struggles as everyone else. Their sexual activities or sexual orientation create additional problems, but that's not who they are."
"When people who are gay or lesbian or bisexual come in to a physician's office and mention they are gay or lesbian, the whole thing seems to start revolving around sexuality when they may be in there for a cold, they may be in there for their annual Pap smear," says Dr. Pierre-Paul Tellier, director of student health and undergraduate medical education at McGill University. "What happens is the whole issue of a patient as a patient is forgotten."
It's something Tellier stresses in his workshop on gay and lesbian issues for family medicine residents. The compulsory seminar begins with videos of gay and lesbian adolescents talking about health concerns, then moves through special medical problems (depression, suicide and sexually transmitted disease) to the creation of a receptive office atmosphere and patient-management issues.
Tellier hasn't always focused on gay and lesbian subjects. He first developed a family medicine workshop on sexuality and the patientphysician relationship because he noticed residents failed to give gynecologic exams and avoided discussing gynecologic matters with patients.
"There's a lot of anxiety around sex and sexuality," he says, citing a study that showed most new family doctors from French-speaking programs don't know how to take a proper sexual history. "It's not just gay and lesbian issues. It's sex in general."
Dr. Deborah Danoff, McGill's associate dean of undergraduate medical education, sees the lack of gay and lesbian material in medical schools as "part of a larger issue, which is how we deal with sexuality. . . . We have in the past 5 or 10 years become more aware that understanding [people's] view of themselves as sexual [beings] and their activities associated with that are very central to all kinds of health and illness issues . . . but there needs to be continuing comfort not only in soliciting the information but also in what you do when you get it."
She says McGill medical students learn about sexuality in first year and again in fourth year, when they spend 4 weeks studying HIV/AIDS. This year, McGill was also a testing ground for a series of teaching modules called Sex, Drugs & HIV (see sidebar).
Dr. Cathy Risdon, who is conducting a study of the experiences of gay and lesbian medical students and residents, says one of her goals is to find ways medical schools can "create a safer environment to make doctors more knowledgeable about caring for gay and lesbian patients and to make the profession as a whole more comfortable with these issues."
Risdon took a "calculated risk" during her first year of residency at McMaster. In 1993, she decided "to come out and use my experiences to educate the profession." She organized a 6-hour workshop for colleagues on homophobia, heterosexism and understanding the homosexual experience, and provided a role-playing exercise that gave participants a taste of what it's like to be a gay resident. As well, gay and lesbian patients talked about their health care experiences.
Today, Risdon does similar but less in-depth presentations to medical students, residents and other groups. She says McMaster's problem-based curriculum offers a few opportunities to review subjects like taking a sexual history. Last May, first-year students got their first exposure to sexual orientation, homophobia and heterosexism in a week devoted to HIV/AIDS.
"I see homophobia and heterosexism as two sides of a double-edged sword," says Risdon. "Heterosexism is more insidious in some ways because the assumption in medical school curricula, in problem-based- learning settings and when we talk about people in general is always that they are heterosexual unless they have AIDS. There need to be people in the problems who also happen to be gay and lesbian and have two kids and have chest pain."
Homosexuality isn't always lumped with disease. Dr. Andrew Chalmers says the University of British Columbia tries "to divorce the concept of illness from sexual orientation" in an introduction-to-clerkship program called alternative couples, in which small groups of fourth-year students meet with gay or lesbian couples for half a day.
Chalmers, associate dean of undergraduate medical education (curriculum), says UBC also has sessions on sexuality, sexual terminology and sexual orientation, but it wasn't easy getting gay and lesbian issues on the agenda. "What we've moved from is nothing to, with great difficulty, putting this in and making it an important part of the curriculum and emphasizing to students that this is as important as examining a heart. A lot of faculty said, 'What on earth are we doing this for?' "
The answer seems pretty straightforward. "The demographics of students are such that they are by and large relatively conservative," Chalmers says. "They have in fact had few opportunities to interact in an appropriate fashion with all of this information and with people of a different sexual orientation. In addition, we have open or semi-open gay and lesbian students."
Through the lecture on sexual orientation, these students have met Vancouver family physician Dr. Robert Voigt, who runs a support group for gay and lesbian physicians. "That's a major gain," Chalmers says.
He says UBC's new curriculum, now in the throes of development, will explore homophobia, heterosexism and other attitudes more thoroughly, particularly in a 3-year stream called the doctorpatient society.
One goal is to "even the balance a bit" between material on gay men and lesbians. Chalmers says "there has been such a tremendous political move from gay men that lesbian women have been somewhat ignored and yet they have quite different issues."
"It's mostly because of AIDS," explains Dr. Ruth Simkin. "You look up 'lesbian' in the Index Medicus and it says, 'See homosexuality.' You look up 'homosexuality,' and there's 99.9% on gay men and AIDS and one little article on lesbians. Lesbians have to be proactive and say, 'Wait a minute here. We're actually a lot closer to heterosexual women than we are to gay men.' "
Simkin, a former family physician in Calgary, now lives in BC and writes extensively on lesbian health (see Simkin R. Lesbians face unique health care problems. CMAJ 1991;145:1620-3). She also gives workshops to medical students and health professionals, one on attitudinal barriers and the unique health concerns of lesbians and the other on creating a receptive office environment and overcoming heterosexual assumptions.
Simkin says lesbians still have problems such as access to a partner in hospital. "I don't know that the situation has changed all that much over time," she says. "The single biggest way it has changed is women are more likely to come out to physicians now than they were perhaps 15 or 20 years ago, and that's a big thing. It's really important that my whole person and my partner and my family are all recognized as such, and I think women are demanding that as more of a kind of right."
But a venue for research is only one step in the right direction. Simkin and others say gay and lesbian issues should be integrated into the curriculum. "To have half a day or a day or 2 days on gays and lesbians isn't very integrating," Simkin says. "It should be an ongoing process.
She also sees a need for "heterosexual allies who address our health care needs," and more courses in which "lesbians and gay men talk openly and honestly about what's happening, and who aren't ashamed of who they are."
"It's probably worth while giving lectures to the totally uninformed," says Dr. Philip Berger. "But I really do believe that the most important way of teaching students and residents is by the conduct of their mentors."
Berger, head of the Department of Community and Family Medicine at Toronto's Wellesley Hospital, graduated from the University of Manitoba medical school in 1974. The only thing he remembers on sexual orientation is "films of behavioural-modification techniques to drive homosexuality out of people's souls."
Berger got his grounding in gay and lesbian health -- and "learned a tremendous amount about hatred towards gays and lesbians" -- when he did a stint at Toronto's Hassle Free Clinic in 1977. "I joined them on the streets, where I've been ever since," says Berger. "That's what educated me, to be quite frank."
Today, about one-third of Berger's patients are gay. His department has six or seven openly gay or lesbian staff and displays a large rainbow flag -- the symbol for the gay movement -- in the hallway. It also has a policy that prohibits patients from discriminating against doctors from minority groups.
Last spring, Wellesley's president "gave his official sanction" for Berger to hold an on-site press conference to respond to remarks by the Reform Party's Dr. Grant Hill about homosexuality and AIDS. "To me, it is an example of how a teaching institution can place itself in a mentoring role," says Berger. "That intervention taught all students and residents at Wellesley how health care professionals can intervene in a political fashion to promote the safety, security and health of a particular population."
Vancouver psychiatrist Dr. Michael Myers would agree. He started giving lectures on sexual orientation more than 15 years ago, then began doing presentations with Dr. Peter Jepson-Young. [Jepson-Young, who died of AIDS 4 years ago, did a magnificent series of television programs on what it is like to live with AIDS. -- Ed.]
"It's not just a curriculum issue," Myers says. "There's got to be attitudinal change. . . . I don't think you can change people's attitudes just by trying to inform them, that sort of thing. I think it's got to do with the people they meet at work."
But there are limitations. "We will always have to accept that a certain number of people in medicine . . . belong to quite conservative religions where homosexuality is a sin," Myers acknowledges. "I don't think I would try to change their beliefs. The only thing I would hope is that they would refer their gay or lesbian patients on, and not try to lecture them or pray over them or with them."