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 segments 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 long-term 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 partner,
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 statuses­e.g., race, ethnicity, sexual
orientation­are
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 monitor­New 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 tests­e.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 stuck 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 teenage 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 inherently­genetically
or biologically­hazardous, but that risk factors are conferred
through
"homophobic fallout." Therefore, homophobia­the socialization
of heterosexuals
against homosexuals and concomitant conditioning of gays and lesbians
against themselves­must 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 see­about 15,000,000 Americans­are 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,
learning 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 patients­especially those dealing
with
aspects of human sexuality­need 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.
Dr. O'Hanlan, assistant professor, Department of Obstetrics and Gynecology,
Stanford University School of Medicine, Palo Alto, Calif., is
president
emerita, Gay and Lesbian Medical Association, Palo Alto. Dr. Robertson
is associate professor, Department of Obstetrics, Gynecology, and
Reproductive Sciences, University of California, San Francisco. Dr.
Cabaj, associate clinical professor of psychiatry, University of California,
San Francisco, is president, Gay and Lesbian Medical Association.
Mr. Schatz is executive director, Gay and Lesbian Medical Association.
Dr. Nemrow is an attending physician in physical medicine, St. Mary'
s Hospital, San Francisco.
The magazine publisher is the copyright holder of this article and
it is reproduced with permission. Further reproduction of this article
in violation of the copyright is prohibited.
Benjamin Schatz; and Paul Nemrow, HOMOPHOBIA Is a Health Hazard.
Vol. 125, USA Today Magazine, 11-01-1996.