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She sits comfortably in a stuffed chair, blanketed by her blue wool sweater, her bald head that once had hip-length dreadlocks now covered by a red wool cap. There is a large poster of a soccer player on the wall. Theresa's 15-year-old son loves soccer. Clark's partner of 20 years, and her son's other mother, is at work. A recent graduate of the University of Washington Family Practice Program, Clark notes the irony of her situation. She was working to help others heal, but the cancer diagnosis "shattered my whole self image of that as a health person." And as a lesbian, Clark is at the center of an emerging set of issues that surround the quality of health care provided to the lesbian, gay, bisexual and transgender (LGBT) community. She is one more number added to the perceived higher breast cancer risk for lesbians. What's the Risk?
One of these social factors is the stigmatization lesbians face from the mainstream culture, a factor that is difficult to measure. For instance, up until 1973, the American Psychiatric Association considered homosexuality a mental illness. In 1996, the FBI reports, anti-gay hate crimes ranked as the third largest category of all hate crimes. The question is often asked, why is lesbian health different from women's health? The answer is always the same: because of the coming-out process the lesbian must undergo with a provider she does not know. "The thinking is -- they're women, so what?" says Clark. "What would be the difference? The effect of the social constraint is hard to assess." "Most people had some level of trauma when they came out," Clark continues. "I don't think it can be underestimated how much that is revisited when people have to continually come out again and again and again. It's, 'OK, how's this person going to respond?' You never know." Being honest about one's sexual orientation is a crucial factor in a patient's health care, contends Kathleen Stine, executive director of the Northwest Policy Institute in Seattle. Unless a physician understands the unique needs a patient might have, he or she may not be fully aware of inherent risk factors or information the patient may need in regard to her personal health. "With health care, the fear of coming out is accentuated because we have this authority figure -- we're not feeling good and health is such a precarious thing that there's fear of adding to our unhealthiness by confronting our provider," says Stine. "Or the provider not liking me, or even a provider who wants to hurt me because they don't like sexual minorities -- I believe that the majority of providers really don't understand what that barrier is." The Barriers Barriers to health care are thought of in terms of three challenges: structural, financial, and cultural, says Dr. Jocelyn White, member of the LHRI and internist with Legacy Health Systems in Portland.
Pressure to keep the visit short, for example, may compromise the trust between the patient and physician, making it harder for the patient to disclose personal information. Many lesbians will avoid health care in general clinics because of these issues and this may pose the greatest health risk of all. There are movements to break down this barrier. In Massachusetts, for example, the Justice Resource Institute has issued a statewide requirement for all health care offices that receive state funding to post non-discrimination signs in the office, as well as other visible cues that speak to the acceptance of racial and sexual minorities, says White. In a National Lesbian Health Care survey, 16 percent of the women
surveyed said they did not receive health care because it was unaffordable. In fact,
30 states have passed constitutional amendments barring recognition of gay marriage,
even if it is legally recognized by the courts. Unlike heterosexual couples, lesbian
and gay domestic partners are not assured mutual health insurance In Vermont, however, the court has ruled that people involved in gay marriages or domestic partnerships are to receive the same benefits as heterosexual married couples. Many local municipalities and private corporations have also expanded insurance coverage for their employees to include domestic partners. And closer to home, the Oregon Court of Appeals was the first court in the nation to decide that the government is required to recognize domestic partnerships in the 1998 Tanner vs. OHSU decision. The court held that all public agencies, including OHSU and public schools, have to provide benefits to domestic partners if they provide benefits to spouses of married employees. It may be difficult for lesbians to find access to free or low-cost health care because many cities offer it only for women seeking birth control. Lesbians who do not need birth control may find it difficult to locate health care services that are affordable, according to the LHRI study. Same-sex partners are also denied rights granted to married heterosexuals in hospitals and clinics. Unless a gay or lesbian couple has signed legal papers, such as a durable power of attorney authorizing mutual medical decision-making, blood relatives, whether or not they know the patient's ethical, medical or religious preferences, can override decisions by a homosexual partner. The Assumptions "The assumptions I saw in medical school -- it was unbelievable to me," reflects Clark. "There were so many assumptions of what other people's lives are like. It was unrealistic. I heard comments like 'the community I am going to work in won't have (same sex) families like that'," she goes on. "You assume a straight world because that is where you are. I can't ever make assumptions of what other peoples' struggles have been. I don't know what their struggles have been." It is crucial that the physician understand the perceived barriers lesbians may face in getting health care, and the impact homophobia might have on the clinics' ability to provide good service, White says. Who's Responsible? It would be ideal if medical schools addressed the medical issues sexual minorities face throughout the medical school curriculum, says White. "I think that the curriculum should continue into the residency program in an integrated way, and I think that part of the way to insure that happens is to make it a licensing requirement."
Students can gain a cultural understanding and awareness of health issues that face sexual minorities in medical school, White says. In a study of physicians attending a sexual minority sensitivity training session conducted by Elizabeth Rankow, MHS, it was found that physicians grew more sensitive and aware of the issues sexual minorities face as a result of the training. In a program in Baltimore, Md., medical students are encouraged to go out and get to know someone who is lesbian or gay before their class in medical issues. This has been shown to increase the students' awareness of the issues sexual minorities face, hence enabling them to question their personal assumptions. "Research supports that there is this major shift in people's thinking and their acceptance of different sexual orientations if they know somebody," says Stine. "And let's face it, that's the exact same thing that happens with African Americans. "As long as we were living as a separate society with blacks on one side of town and whites on the other side of town," she goes on, "it was virtually impossible. It wasn't until the African Americans started moving in next door to white folks that things really started opening up because now you had an actual human face." Asking the Questions
An example of an open question, White points out, might be as simple as, "Are you sexually active?" rather than, "Do you need birth control?" Or, "are your partners men, women or both?" Questions like these will open up communication that might not otherwise occur, she says. Physicians might be afraid of offending and insulting a person, but unless the questions are asked, the "physician isn't going to get good information," says Sally Friedman, senior information and assistance advocate for the Seattle Mayor's Office for Senior Citizens. Friedman and others have developed a program to sensitize the health care community about sexual diversity. The program, called The Rainbow Train, is funded by the city and the state. The objective of the training program is to enable primary care providers and social workers to gain awareness of the unique health care needs of sexual minorities, as well as to "honor and respect the individuality of all people." The Rainbow Train is currently in four pilot clinics in King County and will, over time, expand statewide. "I think it's not being afraid to ask about sexual behavior, saying words like partner and friend instead of husband and wife, just having options on the forms, looking at and recognizing the whole family," Friedman continues. Giving physicians permission to ask questions and make mistakes is very important as they learn about the issues sexual minorities face, she says. A Changing Paradigm In May, 1996, the Journal of the American Medical Association (JAMA) published a report on the "Health Care Needs of Gay Men and Lesbians in the United States." "All patients, regardless of their sexual orientation," it reports, "have a right to respect and concern for their lives and values. Gay men and lesbians face ostracism and discrimination from many sources, including some health professionals." Among JAMA's list of recommendations, it commits itself to a leadership role in: * Educating physicians on the current state of research in and knowledge of homosexuality and the need to take an adequate sexual history. It emphasizes the need for this practice to begin in medical school but must also be a part of continuing medical training. * Encouraging educational outreach to the sexual minority population, educating them on the health risks and myths they may face. * Encouraging physicians to seek out local or national experts in health care needs of gay men and lesbians so that all physicians will achieve a better understanding of the medical needs of the GLBT population. * Encouraging physicians to work with the gay and lesbian community to offer physicians the opportunity to better understand the medical needs of GLBT patients. In October 2000, the National Coalition of Lesbian, Gay, Bisexual and Transgendered Health was formed. Its goals are to increase knowledge regarding these minority populations' health status, as well as to increase professional and cultural competency on the part of health providers and social service workers. In the March 2001 "American Academy of Family Physicians Special Report," it is noted that the coalition won the incorporation of sexual orientation into Healthy People 2010, the U.S. public health plan for the decade. Included in it is the nation's plan to eliminate disparities across geographic, ethnic, racial and sexual orientation lines. "I think it has been hard to get a handle on this," Clark says as she sits back in her chair, wrapping her long fingers around her steaming teacup, "We're talking about a culture that was underground 30 years ago." Clark and others agree that some progress has been made in terms of the LGBT community being addressed in medicine, but there is still a lot more to be done, including here in the Northwest. Medicine is much more than diagnosis and treatment, Clark argues;
it embraces the totality of the patient. "The fact is, you touch people,"
she says. "As a physician you physically are touching people. It's not empty.
The feeling of connection is what people need. It is truly about relationship." In Part II, Elizabeth Pownall will look at lesbian health care access in Eugene, and recall the work of local activist Izzie Harbaugh.
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