Improving Care for Gays and Lesbians

Michigan HIV News Summer 2002

A study from Columbia University and the Gay and Lesbian Medical Association found that communication barriers between physicians and their gay and lesbian patients impede trusting doctor-patient relationships. This prevents gays and lesbians from receiving the screening and prevention services they need, and causes delays in receiving care for acute conditions.

The Midwest AIDS Prevention Project (MAPP) developed a much-needed program for health care professionals to address this problem. Called SCRUBS, the program provides sensitivity training concerning gay and lesbian issues – everything from the health providers looking at their own personal issues concerning gays and lesbians to exploring strategies for improving paperwork and the personal interaction with patients.

MAPP’s Deputy Director, Candice Moench and Program Director, Leon Golson have been the two key trainers for the program, which began a year ago with a grant from the HOPE Fund.

Participants in the 2-hour SCRUBS training become aware of the barriers and obstacles that exist for gays and lesbians in a health care setting. They are told why it is important, and how providers can make their patients aware that they are open to learning about their patients’ sexual behaviors as a means to getting proper health care.

“Some of the things we tell them include, ‘Listen to the patient – the language they are using, watch their overall body language when they are receiving answers from the patient. Some other things they can do to make the patient feel at ease is to wear a rainbow pin or put books around that speak to gay and lesbian issues,” said Golson.

Using appropriate terminology also conveys sensitivity to orientation diversity. “Instead of saying wife or husband – say partner. It might be a straight woman or a lesbian woman, but partner could be inclusive of both,” said Moench. “We try to teach them you don’t have to be obvious about it. You don’t have to have the rainbow flag flying from your office and embrace every gay and lesbian person who walks through the door, but just be aware of little specific things that aren’t hard to do. But for a gay or lesbian person sitting on this side of the desk, those little things really make a big difference.”

MAPP provides a thick resource binder to each agency or medical group that receives the SCRUBS training. This includes a wide range of topics from the coming out process to anal intercourse, club drugs and HIV medications to help the practitioner better understand gay and lesbian-specific issues in order to better treat the patient. The MAPP staff also provide participants a SCRUBS resource card which includes gay and lesbian serving agency and organization information, and sample brochures that can be ordered to make available for their patients. “There isn’t a lot out there however,” said Moench, in the way of brochures on gay and lesbian issues.

In their presentation, the MAPP staff separate the health concerns for men and women and provide participants with the stats on the high risks for these groups, i.e. substance abuse and smoking. “Lesbians are more at risk for breast cancer and ovarian cancer – because they don’t have a tendency to go to the gynecologist or even a (GP).” Research has shown that gay people feel that if they come out to their provider, they will not get adequate care said Moench, and this is only compounded if the patient is also on Medicaid.

Pride Source is a good place to start for gays and lesbians looking for a receptive provider. And of course there is word of mouth advertising among gays and lesbians. But not everyone has those resources, so improving the sensitivity of all providers is important.

From the standpoint of public health, it’s important for all providers to be aware of the special risks for the gay and lesbian population, especially youth for HIV and STDs. Care providers knowing how to approach youth who may be questioning their sexual identity or experimenting can take advantage of an important STD and HIV prevention intervention opportunity.

With research showing the MSM and bisexually active male as such a key in HIV prevention, how can a provider approach his male client in a way that will encourage discussion? Golson said, “ Depending on the client, it could take some time to develop that trust and develop that relationship. But having some physical clues in the office, some articles available, for example. And with the youth, basically not making assumptions. Letting youth know that their confidentiality is going to be maintained. I still hear stories of doctors who not only will disclose a young person’s HIV status, but also their sexual orientation (to the parents). And that usually happens with family doctor situations, where the doctor knows the whole family. But regardless, that doctor was out of line sharing both pieces of information.”

It’s important for the doctor to put the youth at ease about confidentiality right up front said Golson, “By saying ‘I’m not going to call your parents. This stays between us – whatever we talk about in the office,’ I think that will open up doors for other discussions,” said Golson.

Health care providers are on the frontline of prevention. They are the ones who need to be aware – to look for the signs of risk taking and be able to advise on prevention.

It can be a real challenge providing this training to some care providers who just can’t understand why this is an issue they should be dealing with. Moench and Golson agreed that many participants in their groups have said that they avoid the whole subject of sexuality. “One of the questions we ask the participants in training is ‘At some point in your own child’s development did you give any thought to their sexual well-being?’” said Golson. “There is a mind set out there that sexuality will take care of itself.”

It becomes even more difficult providing this training for doctors born in foreign countries, besides the language barrier. “They don’t even feel we should be discussing this,” said Moench.

“They are having a hard time separating their culture and their value system from their professional work,” said Golson. “And when you are working with a diverse group of people, you need to take a part of who you are and what you are and leave it home, so you can go about the business of taking care of your patients in as respectful a manner as possible. Bringing your values into a situation like that can be stifling (for the patients).”

Without accurate information, stereotype assumptions can lead to mistreatment. One example Moench gave was a doctor who assumed that her male patient discussing anal sex was gay. “Identity and behavior are two different things,” said Moench. They tell their groups that putting a label on something can really get you into trouble trying to care for your patient, she said.

Two hours is really not enough to get into all of the issues that need to be discussed and they recommend that the training be continued. “What we are trying to do (in these 2-hour sessions) is open the dialogue,” said Moench. They can provide the resources. “And plant the seed,” said Golson.

Moench and Golson are both more than willing to come back for follow-up SCRUBS sessions. They would like to be able to reach doctors during their medical training, before they develop their ‘bedside manner’.

The real challenge for the SCRUBS team has been marketing the program. After completing the HOPE Fund objectives for training in southeastern Michigan, they received a 3-year grant from MDCH-HAPIS to take the program statewide.

“This is a very hard training to get through the front door,” said Moench. After sending out 400 letters across the state, they only had a response from three. “They (medical professionals) don’t realize it’s an issue. We need people to help us push it into areas that we can’t get into. We don’t have that connection in hospitals.”

The training is free and MAPP is willing to be flexible in scheduling for those who do request the training. “If we can get them for an hour, we’re really happy about it,” said Moench. And they are willing to customize the training for specific audiences. This training can be provided for any health care provider, nurses, doctors, or students. “We did one at Visiting Nurses and they were all health aides,” Moench.

If you know of any health care group that may be interested in the SCRUBS training, please call either Candice Moench or Leon Golson at MAPP (248) 545-1435.

Resources

The Gay and Lesbian Medical Association released two sets of guidelines
on health care for men who have sex with men for health care providers:

"Creating a Safe Clinical Environment for Men Who have Sex With Men" addresses the patient-clinician relationship

"MSM: Clinician's Guide to Incorporating Sexual Risk Assessment in Routine Visits," discusses tailoring prevention messages to MSM.

The guidelines are
available online at http://www.glma.org/medical/clinical/.