When Tara Benesch began applying for medical school, she thought her longtime mentor would write her a recommendation.
"I was telling them, 'Oh, I identify as queer, and I'd love to keep working with the queer community . . .' and subsequently that person said they couldn't write me a recommendation anymore," says Benesch, an M.D./M.S. student at the University of California, Berkeley/University of California, San Francisco Joint Medical Program.
Sadly, this story isn't unusual among LGBTQ students vying for coveted spots in medical school. These students are concerned that being open about their sexual orientation and gender identity could influence -- or harm -- their acceptance and future.
And they're probably right.
A Stanford University paper released earlier this year culled information from online surveys to all medical students throughout the U.S. and Canada; of the 912 respondents who self-described as sexual minorities, about 30 percent reported they concealed their sexual identity in medical school and 40 percent reported being concerned they would face discrimination.
"This person was someone who worked at a medical school -- so it was just kind of telling that there is that kind of unwillingness to talk about these things, even if it wasn't outright homophobia," Benesch says.
Luckily, after Benesch decided to disclose her sexuality on applications (in addition to mentioning it casually in interviews for medical schools), she found a program that she felt would be welcoming to her as it included a lot of LGBTQ faculty to mentor her in the future. Unfortunately, this kind of inclusivity, transparency and an eagerness to accommodate new evolutions in sexuality and accompanying curriculum is a pleasant anomaly.
Medical schools' ongoing discomfort with sexuality and its antiquated notions of how it should be taught -- particularly in regards to LGBTQ issues -- is a serious problem, and one that is affecting patients' health.
Although the importance of sexual health issues are recognized in medical schools in North America, the amount of time spent on educating students on sexuality -- and the quality of this education -- varies widely from school to school, and most of the focus is on preventing pregnancy and STIs, according to a 2013 paper published in the International Society for Sexual Medicine Journal.
The study also found that sexual health programs in med schools don't spend much time on sexual function and dysfunction, female sexuality, abortion or sexual minority groups and the rare interventions to include these subjects have been student-driven. In regards to LGBTQ-specific health issues, students only received a median of five hours of instruction, according to a 2011 Journal of American Medicine paper, and -- as was also revealed in the 2013 paper -- the quantity and quality of that instruction swung widely from school to school.
When it comes to the amount of time spent on how to properly treat LGBTQ patients, Carl Streed, Jr., MD, a LGBTQ health policy and practice expert at Johns Hopkins Bayview Medical Center, said he wants more than just a few hours. He wants the entire curricula across the medical school to address the existence of LGBTQ people and their health needs.
"I don't need hours, I don't need hours set aside. It's not that I need a 'gay day,' it's that I need it mentioned wherever it's appropriate," Streed says.
Medical schools have a long way to go toward discussing sexuality at all, however, explains Bianca Palmisano, owner of Intimate Health Consulting, a national consulting organization for hospitals, clinics, businesses and non-profits that helps practices grow their LGBTQ and sexual health competency.
"When sex is 'private,' it's rendered invisible, and our lack of skills to address an invisible problem are, unsurprisingly, rarely addressed," Palmisano says.
Benesch echoes these sentiments, explaining that there is a tendency for med schools to paint conversations about sex as uncomfortable before they even begin, which is likely the result of how our larger society views sex -- as something we're not supposed to feel at ease talking about.
"In med school, I've heard 'OK, we'll take someone's sexual history later because that can be uncomfortable,'" Benesch says. "I think that saying that is lot worse. It puts this expectation on it that talking about sex has to be uncomfortable for everyone involved."
Gaps in Research on LGBTQ Health
The squeamishness with which medical schools approach the topic of sexuality is compounded by the fact that research on LGBTQ health issues is often limited, and the reality that schools are hesitant to change the shape of curriculum that has existed for years, if not decades.
"Curriculum change takes forever -- there is a lot of inertia around changing any part of a professional curriculum, especially ones that are data-driven," Streed says.
According to Streed, although there isn't enough comprehensive research on LGBTQ health issues, that is luckily beginning to change. The National Institute of Health asked the Institute of Medicine (IOM) to evaluate the medical community's knowledge of LGBTQ populations and identify gaps in the research.
The IOM did find that the overall research on LGBTQ people's health concerns was incomplete, and that information on sexuality and gender identity needs to be as routinely collected as information about race and ethnicity. (Until the '80s and '90s, the health disparities affecting African Americans and other people of color were rarely addressed.)
But, says Streed, there has also been some positive change. "There is now a new requirement for 'meaningful use.' That's a fancy way of saying, 'If you want our money, you have to do what we ask.' So now you have to ask about [sexual orientation and gender identity]. This is so we have medical records, a large national database, that then can be probed for research in the future."
Sexual Health Issues Affecting Lesbian, Gay and Bisexual People
Whether you identify as lesbian, gay, bisexual, queer or any other non-heterosexual identity, there are either assumptions made about your sexual practices that are erroneous and/or unhelpful, or health care providers simply don't ask at all, forcing patients to decide whether they want to announce their sexual orientation to their provider. Benesch says she often finds herself in uncomfortable situations with medical professionals because she may "appear straight" to them. When a provider recently asked Benesch about her sexual history, she said she was queer, prompting a wide-eyed stare.
"I get a lot of wide-eyed stares because that's not what people expect to hear from me," Benesch says. "It just kind of raises a red flag because as a patient I'm like, 'Oh god, this is going to be more awkward than it needs to be.'"
Although concerns about judgment hailing from health-care providers affects a significant swathe of LGBTQ patients, bisexual patients are especially unlikely to disclose their sexual orientation to their doctors. A 2012 study by the Williams Institute found that 33 percent of bisexual women and 39 percent of bisexual men did not disclose their sexual orientation to their health care provider, while only 13 percent of gay men and 10 percent of gay women did not disclose their sexual orientation.
Benesch's experience of shock and stigmatization in regards to her sexuality is not unusual -- many women who identify as queer, bisexual or pansexual hear doctors make assumptions about their sex lives and the number of partners they've had.
"Misconceptions about bi women's health tend to revolve around promiscuity," Palmisano says. "People -- and medical professionals are just people -- love to assume that if you have sex with people of multiple genders, you must be having sex all the time."
Palmisano explains another problem that bi women face is being asked questions that make assumptions about how people should be having sex -- namely that it's "discrete, monogamous and penis-centric." She gave an example of how a doctor may fail to ask the right questions.
"So if I'm a bisexual woman who performs oral sex with a condom with my male partners, but I get fisted by and give analingus to my female and trans partners, my doctor is probably not asking me the right screening questions to assess my risk," Palmisano says.
When it comes to bisexual men -- who are a lot less likely to identify themselves compared to bisexual women -- they're often targeted for conversations that assume they are exposing straight women to diseases and hiding their sexual practices from women they're in relationships with.
"Even though that narrative has been factually torn to shreds, people still believe it," Palmisano explains. "And that means health-care providers still believe it. And they say nasty, nasty things to that effect when men do disclose. So bi men often get the worst of both worlds: erasure and scapegoating."
In regards to gay men, especially gay men of color, they're often targeted in similar ways as bisexual men are, with doctors emphasizing HIV prevention more than with other groups. There are also a lot of assumptions about gay men's sexual behavior that aren't made about straight men's behavior.
"It's this idea that we are trained in algorithms -- we see that a population that is more at risk requires more screening, but the way in which people approach that fact has to have some finesse and some competency," Streed says.
Palmisano agrees that the majority of doctors' approaches needs to change, because HIV prevention should be a point of discussion for all patients, not just those with statistically higher risk.
"Yes, prevalence is highest in gay men of color. But that doesn't change the prevention protocol, which is relevant to everyone. We see this across the board for STIs, it's just most dramatic for HIV. Gay men and people of color get the lectures and the behavioral interventions, bisexuals and queer women get erased, and straight white folks get off scot-free."
A Lack of Understanding on How to Treat Trans Patients
For trans patients, the medical establishment has been particularly slow to adjust. Benesch says that all of her textbooks are fairly heteronormative, and fail to acknowledge the existence of trans people at all.
"Science, which we think is really objective, is actually constructed in this very gendered, heteronormative way. They're talking about 'male health issues' or 'women's health issues' when really they're talking about vaginal health issues," Benesch says.
There's also a lack of consensus about how doctors should approach the issue of taking hormones.
"I hear certain providers say, 'Oh, yes, you can't get pregnant [if you're on hormones]' and I've heard other providers say, 'Oh no, it has to be strictly monitored or it could be very damaging' or they're like, 'Oh, you know they're not as harmful as we thought,' so as a medical student that's been really confusing -- what am I supposed to tell my patients?" Benesch says.
In her consulting work, Palmisano often finds a lack of awareness of how important hormones are to trans patients, because doctors often treat the issue as a minor one, when in fact it's quite dangerous.
"A lot of providers are quick to say, 'You need to come off your hormones' for pretty much any major medical issue, or surgery, without realizing how crucial those hormones are to the well-being of their patient," Palmisano says. "And frequently, stopping the hormones is completely unnecessary for the medical intervention in the first place. But standard procedure is that you stop taking all medications before a surgery, so that's the knee-jerk reaction."
Trans patients also frequently deal with "dead-naming" -- addressing them by birth names and misgendering them.
Smaller medical schools are usually more nimble than larger programs and are able to include more content on LGBTQ health issues as they develop and evolve, Streed says. But that doesn't mean major players aren't making an effort to change. John Hopkins, the University of Washington School of Medicine and Vanderbilt University of Medicine are all making inroads on coverage of LGBTQ health. All three schools were recently named a "Leader in Lesbian Gay Bisexual and Transgender Healthcare" by the Human Rights Campaign.
Although medical students still face issues of stigma, there are particularly welcoming options in some areas of California, such as the Bay Area, where Benesch studies.
"I think at [University of California, San Francisco] we have quite a visible presence of LGBTQ doctors and professors and there's this very liberal gay-friendly space, so it attracts those folks who want to work here," Benesch says.
She recently spoke to a professor who identifies as lesbian and attended an Ivy League school decades ago, and realized how fortunate she was not to face the same resistance.
"She went to school and had a lot of pushback from faculty -- someone outed her and then she turned into the face of the LGBTQ community at that school and faced a lot of backlash from faculty. I remember hearing her story and thinking, 'I'm lucky that isn't how my experience has been.' It was humbling for me . . . med school is hard enough without having to go against people who don't like you for who you are."
Other recent stories include: