Katherine A O’Hanlan, Patricia Robertson, Robert Paul Cabaj, Benjamin Schatz, Paul Nemrow. USA Today. Volume 125, Issue 2618, November 1996.
To a large extent, American society has made gay men and lesbians the brunt of multiple levels of prejudice, with negative assumptions about their morality, trustworthiness, employability, and integrity. (Similar accusations have been made against African-Americans, Jews, and other ethnic groups.) As a result, gay men and lesbians developed a hidden subculture among themselves that only recently has become much more open, and now weaves throughout all segments of society. Surveys of the homosexual community suggest that medical practitioners may lack knowledge of the issues salient in the lives of gay men and lesbians and inadvertently and sometimes purposely have alienated their patients. The gay and lesbian community is much more visible today and is asking for health care that recognizes its unique medical demographic profile and is provided with the same degree of knowledge, sensitivity, and respect afforded other segmeets of America’s large and diverse society. Homophobia is defined as the “unreasoning fear of or antipathy toward homosexuals and homosexuality.” It operates on two levels: internally and externally. internal homophobia represents prejudices that individuals incorporate into their belief systems as they grow up in societies biased against gays and lesbians. External homophobia is the overt expression of those biases, ranging from social avoidance to legal and religious proscription to violence.
There is no scientific basis for homophobic prejudice. The initial classification of homosexuality as a mental disorder in the Diagnostic and Statistical Manual (DSM-III) has been reviewed extensively and found to be reflective only of the social mores at the time it was inserted. The extensive psychiatric literature reveals no major differences in levels of maturity, neuroticism, psychological adjustment, goal orientation, or self-actualization between heterosexuals and homosexuals. A few studies, though, have revealed slightly higher lifetime rates of depression, attempted suicide, psychological help seeking, and substance abuse among the latter. These rates are attributed to the chronic stress from the endurance of societal hatred or the ascription of inferior status. This stress may have worse mental health implications than other stressors because of the frequent loss of familial support systems and the concealment and suppression of feelings and thoughts.
The developmental steps gay men and lesbians must negotiate helps explain the psychological injury to which they are vulnerable. These include recognizing and accepting their homosexual orientation despite pervasive familial and societal condemnation; developing a new identity as a gay/lesbian person, a process labeled “coming out”; and confronting ubiquitous homophobia.
Children, sometimes as young as two to eight years old, who experience homosexual feelings often are isolated and alienated from family members who perceive that heterosexuality is the only acceptable “norm.” In American society, some religious organizations promote homophobia by depicting homosexuality as an immoral proclivity that must be resisted, often telling gay and lesbian children they are wicked and condemned to hell. Educational institutions do not teach children about diversity of orientation, particularly at the ages when most youths begin to discern their orientation. The paucity of gay and lesbian role models in society, combined with negative stereotypes in the media, further diminishes the ability of gay and lesbian youth to develop a positive self-identity and gain respect and understanding from their peers.
The Committee on Adolescence of the American Academy of Pediatrics acknowledged in 1993 that gay and lesbian youth, while attempting to reconcile their feelings with negative societal stereotypes, confront a “lack of accurate knowledge, [a] scarcity of positive role models, and an absence of opportunity for open discussion. Such rejection may lead to isolation, run-away behavior, homelessness, domestic violence, depression, suicide, substance abuse, and school or job failure.”
Children often attempt to conceal their orientation from friends and relatives for fear of reprisals and discrimination, allowing a presumption of their heterosexuality to prevail. In one study, awareness of sexual orientation typically occurred at age 10, but disclosure to another person did not take place until six years later. Homosexual youth find it difficult to maintain a positive self-image, having created a double-life that is not satisfactory in either realm.
Though survey data suggests that the majority of lesbians and gay men are in longterm relationships, misconceptions persist about their ability to form committed and stable involvements, even though researchers have found that 90% of surveyed homosexual couples shared income, lived together, were mutually dependent, and said they were committed for life. Relationship instability in homosexual pairings can occur because of the same common conflicts of all couples, and it can be compounded by effects of cultural homophobia. Internalized homophobia, with its self-doubt and shame, may make some feel they can not develop any relationship at all.
Complications of isolation from the family of origin by gay and lesbian individuals can be manifested in medical crisis. The definition of “family,” for gays and lesbians, necessarily involves creation of a network of close and accepting friends as a family of choice, especially if their family-of-origin has rejected them. Yet, hospitals may restrict visitation privileges of “non-relatives.” Sometimes, when domestic partners have visited their loved ones in the intensive care unit, displays of affection have been met with open disdain by the hospital staff. During a hospitalization, conflict can arise if the couple has not signed contracts for mutual medical conservatorship. Without them, a blood relative, automatically vested with medico-legal authority as next of kin, can override the role and input of the domestic pattner, even though the domestic partner may be the primary caretaker and more knowledgeable of his or her partner’s religious and ethical beliefs.
Many studies demonstrate that Americans who had close friends and relatives had a lower mortality rate than people lacking such connections. A 1992 report from the International Conference on AIDS found a positive correlation between the number of social supports for HIV patients and how well their immune systems fight the disease. Other studies demonstrate that participation in psychologically supportive networks and frequent social interactions are associated with reduced morbidity or mortality from cancer, HIV, and stroke.
Stress in the gay community derives from anxiety, depression, and guilt from being viewed as immoral and deviant, and has been compounded by the effects of the HIV epidemic. Individuals who carry multiple socially marginalized statuses—e.g., race, ethnicity, sexual orientation—are at higher risk of depressive stress.
Substance use can serve as an easy relief, as well as provide acceptance. It numbs painful feelings, tempering the sting of homophobia, and serves as a social lubricant, facilitating the expression of forbidden sexual behavior. For some individuals, alcohol or other substance use and coming out become interconnected. Legal prohibitions and societal disdain effectively have restricted gay and lesbian social outlets to bars and private homes or clubs that typically promote alcohol use. Although there are increasing alternatives to bars and parties, these sites remain the usual initial social outlet for many gay or lesbian individuals, who, in reality, are seeking a wider network of friends.
Homophobia reduces the success of treatment and recovery for gay and lesbian substance abusers. Failure to acknowledge a gay or lesbian identity makes recovery more difficult and increases likelihood of relapse. While gay and lesbian clients are more willing to attend a treatment program which addresses gay issues and provides gay or lesbian counselors, most detoxification and rehabilitation programs show little sensitivity to issues of sexual orientation and generally do not encourage its disclosure. Although research supports the genetic, biological, and biochemical components of both drug use and homosexuality, there are no correlations between the two traits, and there is no suggestion of any linkage.
Domestic violence. Although there is growing awareness in the medical community concerning domestic violence among heterosexuals, there is little awareness that it also occurs in gay and lesbian relationships. Victims and perpetrators may need medical care, but rarely feel able to talk openly about their problems, thus perpetuating a cycle of denial and continuing violence. The National Lesbian Health Care Survey reported that 11% of lesbians had been victims of domestic violence by their partner, while the incidence of domestic violence in gay male couples is estimated at 15-25%.
Public violence. The Hate Crime Statistics Act requires the Federal government to collect data obtained by police agencies. However, only 12 states include homophobic violence in their definition of hate crimes; 17 have hate crime laws that do not count violence based on sexual orientation; and 21 do not count hate crimes.
The 1994 National Gay and Lesbian Task Force Report on Violence described 1,813 instances of harassment, threats, assault, vandalism, arson, kidnapping, extortion, and murder over 12 months in the six cities they monitor—New York, Minneapolis/St. Paul, Chicago, Denver, Boston, and San Francisco. Homicides against gay men and lesbians appear to be more grizzly and more likely to involve mutilation and torture, and are more likely to go unsolved, according to a two-year national study. reflecting the intensity of anti-gay hatred.
While physical harm caused by anti-gay violence is immediately obvious, psychological and emotional injury also can occur. These include post-traumatic stress and chronic pain syndromes, phobias, eating disorders, and, most commonly, depression.
Effects on earnings and medical insurability. In an analysis of the 1990 census data, in which gay and lesbian couples could identify themselves as such, it was found that, while 38% of lesbian respondents were college graduates, compared to 34% of male homosexuals and 18% of married heterosexuals, lesbian couples had the lowest income of the three groups. A reduced earning potential may result from experienced or anticipated discrimination, thus inhibiting gays and lesbians from seeking higher-profile, higher-paying jobs,
Barriers to insurance for both lesbians and gay men may keep them from obtaining yearly screening tests and seeking care early in the course of a disease. In one study, 58% of lesbians reported not seeking medical care when they felt they needed it because they lacked insurance or the financial resources. Recently, some health insurers have begun to deny insurance to men perceived to be gay (e.g., over 30 years of age and unmarried), regardless of their HIV status.
Effects on the doctor-patient relationship
Homophobia can lead to misrepresentation of facts by patients and misinterpretation of facts by physicians. Numerous studies have revealed a significant prevalence of homophobic attitudes among all types of health care practitioners in the U.S.
In the 1994 survey of the 1,311 members of the American Association of Physicians for Human Rights, now called The Gay and Lesbian Medical Association, more than half of the respondents specifically had observed the denial of care or provision of reduced or sub-optimal care to gay or lesbian patients, and 88% have heard their physician colleagues make disparaging remarks about gay or lesbian patients relating to their orientation. While 98% of respondents felt that it was medically important for patients to inform their physicians of their orientation, 64% believed that, in so doing, they risked receiving substandard care. Additionally, 17% of practicing physicians reported being refused medical privileges, employment, educational opportunities, and referrals from other doctors because of their orientation. Social ostracism and verbal harassment or insults by their medical colleagues because of their orientation were reported by one-third of physicians and one-half of medical student respondents. Summarizing the survey results, just 12% of respondents felt that “gay, lesbian or bisexual physicians are accepted as equals in the medical profession.”
Medical students have reported frequently hearing overtly hostile comments made about lesbians and gay people by attending physicians during clinical teaching rounds. They express frustration with the limited information about homosexuality in their curricula, and have requested that medical educators present lectures that are updated, inclusive, and deal directly and honestly with gay and lesbian-related health issues.
Homophobic attitudes of nurses, medical students, and physicians are perceived by patients and negatively affect their experience of and the quality of their medical care. In one study, 72% of lesbians surveyed reported experiencing ostracism, rough treatment, and derogatory comments, as well as disrespect for their partners by their medical practitioners. Several studies document extremely negative reactions from health care practitioners commencing after gay or lesbian patients revealed their orientation. More than two-thirds of lesbians report having withheld information about their sexual behavior, fearing sanctions or repercussions if they did. As a result, 84% were hesitant to return to their physicians’ offices for new ailments and were less likely to come back for indicated medical screening tests—e.g., Pap smears, blood pressure, cholesterol, stool blood assays, etc. One respondent indicated: “It’s like putting your health in the hands of someone who really hates you.”
Many physicians have informed their lesbian patients that they do not require Pap smears because they are assumed to be in a low-risk category, having no sex with males. However, most studies reveal that 77-91% of lesbians have had at least one prior sexual experience with men. The interval between Pap smears for lesbians was reported to be more than twice that for heterosexual women. As many as five-10% of respondents in two large surveys never have had a Pap smear or had one more than 10 years ago. Moreover, one-fourth of lesbians over age 40 in a Michigan study never have had a mammogram.
Lesbians, in one study, weighed more and had less concern for appearance and thinness than heterosexual women. High body mass increases risk for breast and endometrial cancer, diabetes, heart and gall bladder disease, and hypertension. Some studies suggest that single women have higher rates of cigarette abuse. Considering all of these factors, lesbians may experience greater morbidity or mortality from multiple cancers and heart disease, especially if they defer seeing a physician until symptoms or signs become extreme or acute.
Outside the context of HIV, representative data on health and psychology issues have not been obtained from the gay and lesbian community because researchers have not considered sexual orientation an important question in national probability health surveys. In a review of journal articles reporting research on lesbian and gay men, it was observed that authors rarely involved research participants beyond the role of generating data, frequently failed to report conditions of consent, hardly ever cited feedback to participants, and virtually never indicated using the data to promote social action. This is critical because, if reliable demographic information about gay and lesbian health showed a higher incidence, morbidity, or mortality from cancers or heart disease, screening or health education programs could be instituted and targeted to the population at risk. The psychological needs of the gay and lesbian population also could be addressed more effectively, as well as the issues of ethnic minority gays and lesbians.
Once AIDS was detected among gay men in 1981, scientists at the U.S. Centers for Disease Control (CDC) quickly recognized its potential for rapid spread and lobbied their superiors for funds to research and prevent the epidemic. Given the perception of AIDS as a gay disease, though, such funding was nearly impossible to obtain from an administration that owed much of its election victory to political conservatives. It was not until two years later, after more than 1,000 Americans already had been diagnosed with AIDS, that the Reagan Administration finally requested funds from Congress to address the epidemic.
While AIDS research funding has increased dramatically in recent years, persistent antipathy towards homosexuals has made it difficult to obtain Federal funds for prevention of HIV infection among gay and bisexual men. In 1987, an amendment was passed by the Senate prohibiting the CDC from funding any materials that would “promote or encourage … homosexual activities,” which precluded creation of any prevention informational material specific to the gay community. While this law eventually expired, other obstacles took its place. Regulations subsequently required any CDC-supported prevention materials aimed at gay or bisexual men to be reviewed by a panel representing a “reasonable cross-section of the general population” to ensure that the materials were not “offensive to a majority of adults beyond the target audience.” A Federal court struck down these regulations, finding that they hampered AIDS prevention efforts.
After a Reader’s Digest article criticized the CDC for “promoting homosexuality” by funding an AIDS prevention agency targeting gay and bisexual men of color, CDC funding to that agency was cut. A similar difficulty was encountered in obtaining information from the medical professions about lesbian and gay health in general. Numerous requests by members of the American College of Obstetricians and Gynecologists to its Patient Education Committee to include information about sexual orientation in brochures dealing with teen-age sexuality, teaching children about sexuality, sexual dysfunction, and sexually transmitted diseases have been ignored.
Upon inquiry regarding the absence of HIV prevention materials directed towards individuals and communities at highest risk, U.S. Assistant Secretary for Health James O. Mason responded: “There are certain areas which, when the goals of science collide with moral and ethical judgment, science has to take a time out.” Health and Human Services spokesman William Grigg explained that, “when you’re fighting a fire, you control it from the outside and let the center burn. The same holds true for medicine.”
Creating and implementing solutions
It is important to recognize that being gay or lesbian is not inherently—genetically or biologically—hazardous, but that risk factors are conferred through “homophobic fallout.” Therefore, homophobia—the socialization of heterosexuals against homosexuals and concomitant conditioning of gays and lesbians against themselves—must be recognized by physicians as a legitimate health hazard.
Progress already has been made in multiple precedent-setting examples. The American Medical Association (AMA), at its 1993 annual meeting, voted to include the words “sexual orientation” in its non-discrimination statement, after having rejected this motion for four consecutive years. The American Medical Women’s Association (AMWA), the 12,000-member association of female physicians, passed, without opposition, a policy statement urging an end to discrimination by sexual orientation. Moreover, AMWA encouraged: “national, state, and local legislation to end discrimination based on sexual orientation in housing, employment, marriage and tax laws, child custody and adoption laws; to redefine family to encompass the full diversity of all family structures; and to ratify marriage for lesbian, gay and bisexual people … creation and implementation of educational programs … in the schools, religious institutions, medical community, and the wider community to teach respect for all humans.”
Recognizing the importance of knowledge about diversity of sexual orientation in clinical practice is an important part of the solution. Physicians must be aware that as much as six percent of the patients they see—about 15,000,000 Americans—are gay, lesbian, or bisexual, and that these individuals express part of the normal range of human sexuality. Their unique health issues need to be heard, respected, and addressed. A prerequisite is the learned genuine appreciation of the diversity that exists in America today. Such information must come from organized curricula in medical school and/or residency training programs. The Temple University School of Medicine provides its medical community with a resource guide that addresses many of the issues described above. The American Psychiatric Association has sponsored “A Curriculum for Learning About Homosexuality and Gay Men and Lesbians in Psychiatric Residencies,” which describes educational objectives, reaming experiences, and implementation strategies for sound clinical practice.
Health care providers can do much to reduce homophobia within their practices. The need for a trusting, supportive, and open doctor-patient relationship is critical in compiling a thorough and accurate medical history of each patient. There are numerous ways physicians can make their practices more welcoming of gay and lesbian patients.
* Physicians routinely should ask, when discussing sexual behavior, whether the patient is sexual with men, women, both, or neither. Doctors clearly should dispel any assumption of heterosexuality by using inclusive language with all patients, inquiring about behavior, not labeling the orientation, and accepting the information with neutrality. Simply having a non-judgmental, non-homophobic attitude is not enough. A responsible practitioner must convey that attitude to all patients.
* Using generic terms such as “partner” or “spouse” rather than “boyfriend” or “girlfriend” will encourage trust in the physician by removing assumptions. It would be useful for health care providers to become familiar with language commonly utilized in naming sexual behaviors. Comfortable use of these terms will facilitate taking the health history by enhancing clarity of communication.
* Registration forms and questionnaires that require patients to identify themselves in heterosexual terms such as single or divorced should be revised to include “significantly involved” or “domestic partner,” in order to avoid excluding gay or lesbian patients.
* Informational brochures for patients—especially those dealing with aspects of human sexuality—need to include facts about homosexuality. Educational pamphlets in the offices of gynecologists, pediatricians, and family practitioners could provide life-affirming information to youngsters and become an educational source for parents, possibly impacting rates of youth suicide as well as public violence and discrimination.
* If the lesbian or gay patient is partnered, the health care provider should welcome the patient’s significant other and routinely encourage the couple to consider obtaining a medical power of attorney document, especially prior to any elective surgery or obstetrical delivery. Just as for married individuals, the physician should provide support for the stability of the patient’s relationship. The doctor should have the skills to counsel for gay-related anxieties and safeguard against referrals to homophobic colleagues.
In order to provide general information as well as specific education for all adolescents, physicians should not reserve their questions about orientation for the gender-atypical individuals, the “sissy” boys and “tomboy” girls. It is impossible to predict which youth are struggling with issues of orientation, and all youngsters can benefit from the non-biased demonstration of the health care provider’s positive attitude toward issues of orientation. While gender-atypical youth ultimately may develop a homosexual orientation, negative parental attitudes serve only to alienate the parent and isolate the child. It is irrational to classify such behavior in youth as abnormal when homosexuality in adults is not considered in that manner. The American Academy of Pediatrics (AAP), recognizing homosexuality as a natural sexual expression, recommends psychotherapy for gay and lesbian youth who are uncertain about their orientation or need help addressing personal, family, and environmental difficulties that are concomitant with coming out. The AAP also recognizes that families may experience some stress and need information while supporting an individual’s newly expressed orientation and recommends that families contact organizations such as Parents, Family, and Friends of Lesbians and Gays or obtain therapy.
The AAP further states: “Therapy directed at changing sexual orientation is contraindicated, since it can provoke guilt and anxiety while having little or no potential for achieving changes in orientation.” Conversion therapy is ineffective, unethical, and harmful to the individual. In 1994, the American Medical Association issued its concurrence in an updated policy statement regarding the medical treatment of gay men and lesbians. One of the conclusions of the report was that therapy to change sexual orientation no longer is recommended, but psychotherapy may be necessary to help gays or lesbians become more comfortable with their sexuality and deal with society’s prejudicial response to them. The AMA report agreed on the importance of obtaining an accurate, unbiased sexual history from all patients with a focus on behavior, recognizing the alienation of many gay men and lesbians from the medical system, the ubiquity of prejudice against homosexuals, and the psychological effects of the prejudice.
Physicians can encourage their practice group and medical centers to make available benefit packages that insure all committed couples. Regardless of their orientation and political or religious affiliation, doctors must provide the highest standard of care to all patients by discarding those views which science does not validate. They have a responsibility to examine their attitudes about homosexuality and recognize the views they hold which are not consistent with facts. Health care providers have a unique opportunity to influence others in American society to align their attitudes with objective information. Public education of both adults and children about the diversity of orientation will reduce the pervasive, unfounded disdain for homosexuals and maintain lesbian and gay individuals’ self-respect. Civil rights legislation proscribing discrimination and providing legal recognition for the unions of lesbian and gay families will restore legal, societal, and financial equity to the marginalized population. Improved access to health care, increased integration into family and society, and heightened life satisfaction and productivity will result when homophobia is recognized as the major health hazard it poses to gays and lesbians.