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The culture of medicine is a reflection of the broader social culture so we should not be surprised that homophobia is the single most important health risk facing lesbians and gay men[1]. People who identify as LGBT, or who are thought to be from one of these groups, continue to be victims of violence. In the United States, they are the 3rd most persecuted group after race and religion, and in 41 states, discrimination based on sexual orientation is legal[2] [3]. The prevalence of homophobia in our society permeates the health care system as well. Many LGBT individuals fear coming out to their health providers, there is evidence that this is true for 53-72% of lesbians[3]. This fear of discrimination is not unfounded, there is evidence that health care providers lack understanding and can behave insensitively which create barriers to accessing services and result in a lack of appropriate care[4].

The average medical school training devotes very little time to LGBT health issues, resulting in physicians who do not have the knowledge to provide culturally competent care to their LGBT patients[4] [3] [5].

In 1973 the American Psychiatric Association removed homosexuality from its categories of mental disorders and in 1986, it removed "egodystonic homosexuality" as well. Despite this, some medical professionals continue to view homosexuality as abnormal or dysfunctional and many have expressed discomfort with gay men and lesbian patients[6].

The invisibility and systemic discrimination against same-sex couples impacts negatively on the health of LGBT individuals. Health insurance plans often don’t include same-sex partner benefits,35.  The lack of legal recognition of same-sex partners has implications for visitation rights, health care decision making, and access to information[7] [6] [3] [8].

Gay men are more likely able to access health care than lesbian women[9]. Women’s health in primary care tends to be focused on reproductive health including family planning and STD prevention[4] [3]. Much of the counseling and disease prevention education assumes women are having sex with men and lesbians often receive unsolicited birth control counselling[4] [3]. This heterosexist focus renders lesbian women invisible and compromises health promotion and prevention[4] [3].

In a 1998 survey of 575 lesbians, gay men and bisexuals from the New York area, only 29% of the participants were asked about their sexual orientation, even though 70% were "out" to their providers, 17% of the participants avoided or delayed seeking medical care due to their sexual orientation. Finally, men and HIV positive individuals were more likely to perceive their provider as sensitive to their health concerns, while women worried more about negative provider reactions to their coming out.[10]

In a survey of 60 pediatricians, 22% of the respondents believed that physicians should assume a patient is straight unless told otherwise, and 68% did not include sexual orientation questions in a sexual history for any age group[5]. This reluctance or avoidance on the part of health care providers to ask about sexual activity and orientation places the burden on the patients and contributes to heterosexist biases in medical care.

When caring for the LGBT population, it is important to account for all the categories of "otherness" in order to understand all of the cultural influences in the individual patient’s life. It is important to understand that different cultures have different standards of sexual expression and different consequences for breaking away from the norms of that particular culture. Most organized religions condemn homosexuality. LGBT individuals of colour often have strong support systems from both the gay community and their community of colour if they remain "in the closet", however, they may also experience discrimination on the basis of colour in the LGBT community and they may risk losing the support of their community of colour if they come out[4].

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1. Peterkin A, Risdon C. Caring for Lesbian and Gay People: A Clinical Guide. 2003. University of Toronto Press Incorporated. Toronto, Ontario.

2. Lee R. Health care problems of lesbian, gay, bisexual, and transgender patients. Western Journal of Medicine. 2000;172:403-408.

3. Solarz, AL Ed. Lesbian Health: Current Assessment and Directions for the Future. Washington DC. National Academy Press; 1999.

4. Kaiser Permanente National Diversity Council. A Provider's Handbook on Culturally Competent Care: Lesbian, Gay, Bisexual and Transgendered Population. Oakland, CA. Kaiser Permanente; 2000.

5. East JA, El Rayess F. Pediatricians' approach to the health care of lesbian, gay, and bisexual youth. Journal of Adolescent Health. 1998;23:191-193.

6. Anonymous [Council on Scientific Affairs, American Medical Association]. Health care needs of gay men and lesbians in the United States. Journal of the American Medical Association. 1996;275(17):1354-1359.

7. Barbara AM, Quandt SA, Anderson RT. Experiences of lesbians in the health care environment. Women & Health. 2001;34(1):45-62.

8. Finlon C. Health care for all lesbian, gay, bisexual, and transgender populations. Journal of Gay & Lesbian Social Services. 2002;14(3):111-118.

9. Scarce M. Smearing the Queer: Medical Bias in the Health Care of Gay Men. Binghampton NY. The Haworth Press, Inc.; 1999.

10. Stein GL, Bonuck KA. Physician-patient relationships among the lesbian and gay community. Journal of the Gay and Lesbian Medical Association. 2001;5(3):87-93.

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