Study to help gay patients 'come out' to doctors

Credit: Stanford LGBT Medical Education Research Group Stanford LGBT Medical Education Research Group

Mitchell Lunn, Eric Tran, William White Jr., Juno Obedin-Maliver, Elizabeth Goldsmith and Leslie Stewart have launched a study on how medical students are trained to treat gay, lesbian, bisexual and transgender patients.

Every time he goes to a new doctor, Mitchell Lunn, faces the question anew: Should he tell his doctor he's gay?

'The question always comes up,' said Lunn, 27, a Stanford medical student from North Dakota. 'Do I want to come out or not?' This hesitancy is common with lesbian, gay, bisexual, and transgender patients when meeting with a doctor for the first time. Often they're scared away by homophobic comments, or simply by a basic lack of knowledge on the part of their doctor as to their unique health care concerns.

'The fear of insensitivity from their doctor has driven many patients away,' Lunn said. 'Sometimes never to return.'

In an effort to continue the ongoing struggle of LGBT health activists to get adequate training of medical students on the unique health-care needs within their community, a group of four medical students at Stanford including Lunn have organized their own on-campus research group, called the Lesbian, Gay, Bisexual, & Transgender Medical Education Research Group.

In the spring, the group will send out surveys to the deans of medical education at schools in the United States and Canada to determine what is being taught, before moving forward with recommended improvements.

'Right now, it's just not known exactly what is being taught in medical schools,' Lunn said. 'We have a little bit of content at Stanford, which is good. But nobody knows for sure about what other schools are teaching.'

Questions on the survey range from: 'When learning how to conduct a sexual history, are students at your institution taught to obtain information about same-sex relations, e.g. asking 'do you have sex with men, women, or both?'' To: 'Is there a clinical clerkship site that is specifically designed to facilitate LGBT patient care?'

The survey also provides a glossary of terms such as, 'Sex reassignment surgery: the genital alteration surgery that transgender individuals sometimes undergo ... previously referred to as 'sex change operation.'' And: 'Intersex: In which a person is born with a reproductive or sexual anatomy that doesn't fit the typical definitions of female or male.'

A similar survey will next be sent out to all medical students.

The four students - Elizabeth Goldsmith, Leslie Stewart, Juno Obedin-Maliver and Lunn - became aware of the lack of research regarding LGBT content in medical schools on a national level and decided to form their research group after attending the 25th annual conference of the Gay & Lesbian Medical Association, or GLMA, in 2007.

An earlier survey of medical students in 1994 by the GLMA found that 'overwhelmingly, medical students had a very negative attitudes toward the LGBT community,' said Tri Do, MD, assistant adjunct professor of medicine at UC-San Francisco and a leading LGBT health-care activist.

'Responses showed that many students believed people with HIV deserved what they got. This was 1994, before (the comedienne/actress) Ellen DeGeneres came out. It was very controversial. Physicians didn't want to come out; they didn't want to teach these things for fear of being branded.'

More than a decade later, social attitudes have begun to change, Do said, but there remains a general level of ignorance among health-care professionals as to the documented health disparities within the LGBT community. Health disparities - such as increased risk factors for breast cancer among lesbians, higher rates of depression and anxiety due to homophobic discrimination, and increased rates of hepatitis among gay men - just aren't well-known.

'Many providers, even knowledgeable LGB ones, do not know how to address transgender health concerns or how to address racial disparities,' Do said.

The Stanford students' goal is to help battle this ignorance. 'Our community faces significant barriers to accessing safe, appropriate and comprehensive medical care,' the research group wrote on its Web site. 'These barriers may exacerbate compelling health problems that occur disproportionately among LGBT individuals such as increased rates of certain cancers, infections, chronic diseases.'

The group received a small contribution from Stanford including money from the Haas Center for Public Service at Stanford to help launch its study, and the center's director, Gabriel Garcia, MD, who is also the medical school's associate dean for admissions and professor of medicine, is an advisor to the students, along with other members of the faculty. 'There is ample evidence that the LGBT community is poorly served by our health-care system,' he said. 'This study will challenge all health-care workers to understand their biases and develop the skills and knowledge needed to provide good health care to this community. Stanford should take immense pride in the work that Lizzy, Leslie, Juno and Mitch are doing.'

Medical student involvement in updating curricula could be key to making changes to meet the needs of the LGBT community. Emily Ferrara, assistant professor at the University of Massachusetts Medical School, and two UMass colleagues - including a student - presented a workshop at the 2008 annual Association of American Medical Colleges meeting providing guidelines for medical schools on how to respond to the needs of LGBT students and patients. It was the first time the topic had been on the agenda, she said. At the University of Massachusetts, the medical school has been engaged in curriculum innovation on LGBT health for the past 10 years, and most recently added the topic of transgender health to the required ob/gyn clerkship curriculum.

'For the average faculty member and student, it's really eye-opening to learn about the unique patient care needs from the transgender patient's perspective,' Ferrara said. 'But even here in Massachusetts, where same-sex marriage is legal, we have a long way to go to improve the care provided to all LGBT patients.'

Stanford medical student Obedin-Maliver, 30, from New York City, first became involved with helping to shape the LGBT curriculum at Stanford by helping organize Stanford's spring 'Queer Health and Medicine' course which meets once a week and features guest lecturers and panel discussions.

She knows first-hand just how important a sensitive and well-informed medical interview is to getting adequate care for LGBT people.

'I routinely get asked about birth control,' said Obedin-Maliver, discussing her experiences as a lesbian meeting with a new doctor. 'I awkwardly stumble through explaining that that's not necessary and why. But they don't ask the necessary follow up questions like, 'Are you monogamous?' 'Have you been screened for sexually transmitted infections?' 'Are you practicing safe sex?''

She added, 'Taking a really comprehensive sexual history for any patient is essential. Medical students need to learn to ask these questions with absolutely every patient, from the 89-year-old grandmother to the 16-year-old wearing a rainbow T-shirt.'

But even more important than taking a sensitive history is providing accurate medical information. 'I've had friends and partners given the wrong information that has led to medical problems,' Obedin-Maliver said. 'The idea that women can't transmit sexually transmitted infections to one another, that's not true. We need to know what is the HIV transmission rate between two women, what is the rate of sexually transmitted infections. You just don't learn these things in medical school.'

More information on the research group is available at: Undergraduate students William White, Jr. and Eric Tran are also contributing members of the group.

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