Adam Lake, MD
When it comes to LGBTQ+ health, the first topic that I often see is related to HIV and STIs.
While this is certainly one of many health disparities that emerge when comparing the LGBTQ+ population to the population as a whole, overdoing the focus on this topic can be divisive. The health disparities extend to mental health, cardiovascular risk, and use of preventative care.
As a family doctor and HIV care provider, I see this bias leading to an earlier diagnosis in a young gay man who had a sore throat that wouldn’t quit, but missed completely in the straight married woman with unexplained low cell counts despite extensive testing and multiple subspecialist referrals. This pattern is borne out in many, many, many studies.
True, sexual (and/or romantic) identity is what can be used to define the LGB population, though same-sex sexual activity is not always the defining factor for self-identification. As a juxtaposition, Trans*, queer, and gender non-conforming populations generally are defined by their non-cis gender identity and not sexual identity. The impact we have on Trans* patients seeking health care is especially striking with 28% putting off care due to discrimination and disrespect even when sick or injured.
The challenge here is deeper than where we may immediately recognize. The hard part is not seeing the nuance in the population prevalence: this is about being a safe space for all patients.
As teaching family doctors, we have a great opportunity to demonstrate empathy and to teach appropriate care for all. I encourage my learners to find a way to add sexual history inquiries into standard questions and to create a safe space to have candid dialog between provider and patient.
I will never forget a true conversation I had with a 60-year-old man in our more rural practice:
Me: Do you smoke cigarettes?
Patient: Nah, quit that years ago.
Me: Any alcohol?
Patient: Here and there, you know, nothing on a regular basis.
Me: Any other drugs?
Me: Are you currently sexually active?
Me: With men, women, or both?
Patient: Both, but I generally only have sex with guys when my wife and I are doing coke…
As you can imagine, more questions followed. While this patient identified as straight, I have found again and again that simply asking about sex will often lead to more accurate histories from patients in other domains of information. Questions about this have helped me break down my own preconceived notions of sexuality, especially when encountering unexpected answers in patients who challenge our assumptions.
To change the health care system as a whole is not within the power of a single one of us, but affecting that which is within our influence is possible. You may have the ability to affect curricular development or develop community educational activities. Or you may have the ability to personally open the eyes of your students, residents, or colleagues. Whatever your power may be, go out and make the change.
We owe it to all our patients. For patients invisibly attracted to those on the same side of the gender spectrum who have never revealed that to a provider. For the transwoman who just wants to talk to you about her shoulder pain and not her genitals. For the straight woman with the sore throat that won’t go away. For the queer teen who just can’t take it anymore. I want our patients to know that we care.