AMA Journal of Ethics^®

Case

Dr. James is a young primary care physician starting out in the rural community of Cedar, where he shares a practice with one other physician; the next nearest outpatient care center is 35 miles away. Dr. James was sorely needed in Cedar. His colleague is minimally trained in obstetrics and gynecology, and Dr. James has a special interest and training in women’s health. He likes the size of the community and believes he makes a difference in the health of his patients. He has become Cedar High School’s sports medicine physician and volunteers at other civic events within the community. Dr. James is gay, and although he was out during medical school and residency, he has not been open about his sexual orientation within the Cedar community for fear of the reception he might receive.

Dr. James sees Mrs. Raymond often. She is a friendly woman having a complication-riddled pregnancy. One day after her exam, Mrs. Raymond and Dr. James were chatting about Cedar High, where Mrs. Raymond’s oldest child was due to start in a couple of months. Mrs. Raymond alluded to a recent controversy in a nearby town over a student’s desire to bring a same-sex date to his senior prom and said, “I’m just worried…how can we be sure kids here aren’t…that way? Dr. James, is there anything you can do to make sure there’s nothing like that going on at Cedar High? You try to keep your kids safe, to protect them, but you never know what bad influences are out there.” Dr. James did not speak, so Mrs. Raymond continued, “I mean, if I ever found out that there was one of them here—especially a teacher or a coach—I don’t know what I’d do.”

Commentary

This case raises some fundamental ethical questions about the patient-physician relationship, including: What constitutes physicians’ private information? Is this information germane to informed consent or patient communication, and are patients entitled to know private details about their physicians? Do physicians have a duty to disclose such information? What are the pros and cons of disclosure?

Homophobia in the Patient-Physician Relationship

To understand the nuances of disclosure of sexual orientation by health care professionals, it is important to review the impact of homophobia on health care. Homosexuality was considered a pathologic disorder by the Diagnostic and Statistical Manual of Mental Disorders until 1973 [1]. To this day, societal bias against gay physicians persists. In one 1998 study, more than one in 10 patients responded that they would refuse to see a gay, lesbian, or bisexual (“GLB”) physician. More than 50 percent of the 346 respondents reported that “GLB physicians would be incompetent” and that they (the respondents) would feel “uncomfortable with a GLB physician” [2]. Ten years later, Lee et al. found that more than 30 percent of respondents would change doctors if they found out that theirs was gay, and more than 35 percent would change providers if gay clinicians were employed where they received health care [3].

Disclosure of sexual orientation provides an opportunity for discussion and education about gender, sexuality, and other social contributors to health status. Yet, do physicians have a duty to engage in such discourse when it pertains to themselves and not patients? Many considerations factor into this very personal decision, including one’s comfort level with discussing sexual orientation in general, one’s sense of perceived threat, and one’s willingness to disclose personal characteristics and information.

Physician Privacy: What Is It?

While some laws and codes [4-6] ensure a measure of professional privacy for information about physicians’ performance, finances, and clinical practices, there is no existing legal provision for personal privacy for physicians—i.e., the protection of information or details not arising from or pertaining to the physician’s professional qualifications and obligations or clinical knowledge, performance, and judgment—probably because that information is not related to performance.

Is Personal Disclosure Necessary for Patient Informed Consent?

There is no reason to believe that a physician’s sexual orientation would impact performance rates or health outcomes any more than would other characteristics, for example, the physician’s sex. What sexual orientation can affect is some patients’ perceived comfort and health behaviors. On the one hand, disclosure to a gay patient can demonstrate affinity and lead to improved communication and an enhanced patient-doctor relationship; on the other hand, with a conservative patient, such disclosure can lead to requests for chaperones or gender concordant clinicians.

But to what degree should particular patients’ possible comfort levels to be indulged? Patients do not have any medical reason to know their care giver’s sexual orientation or any other invisible characteristic that does not affect patient care or outcome.

Other Consequences to Consider

Though Dr. James does not have an obligation to inform Mrs. Raymond of his sexual orientation, her question about gays in Cedar should lead him to consider his long-term strategy for managing the overlap between his professional role and personal life. In a conservative community, disclosure of sexual orientation can ruin a gay physician’s practice if patients with homophobic beliefs decide to seek care elsewhere. Physicians who are gay or bisexual could face discrimination, loss of practice, and the loss of income or, at least strain the patient-doctor relationship. If Dr. James is the only doctor who provides obstetric care in the community, it is less likely that pregnant patients would leave his practice, but the potential for discrimination from this patient and others remains.

At the same time, the costs of nondisclosure are not to be discounted. Loss of personal integrity, the emotional and psychological costs of “pronoun switching” and actively managing one’s presentation can be time-consuming and exhausting. Evasions and omissions of commonly discussed topics in social situations can add to awkwardness in the patient-physician relationship. Innocuous social and friendly questions can lead to the need for disclosure or lying. Abha Agrawal writes of the challenges of answering a patient’s questions about her personal life—she had lived with her woman partner for 20 years and considered herself married—during a pelvic exam. Having told the patient in question she was married, she was then asked follow-up questions about her “husband,” and, in the heat of the moment, answered as though her partner were a man.“In that split second, that was the best decision I could make. Would it have been better to tell her the truth” [7]?

In a 2004 editorial in the British Medical Journal, David Hughes writes

Although health professionals may resolve in advance either to be open about their sexual orientation (to "out" themselves) or to avoid disclosure…it would be unrealistic to think that every routine consultation could be prefaced by an explanation of sexual preference. Most practitioners find themselves carefully negotiating their way through interactions, making decisions from one moment to the next about how relevant their sexual identity may be to the situation and just how open to be [8].

On the positive side, Jennifer Potter writes that being “out” with one’s patients can be empowering. “It allows me to be myself, to integrate my public and private lives, voice my opinions and celebrate all my achievements, and work passionately to increase tolerance and acceptance” [9]. Moreover, the patient-doctor relationship is based on trust, and “upfront disclosure avoids embarrassing people who might otherwise assume heterosexuality” [9].

Dr. James, in some ways, is lucky about the circumstances in which the topic has come up. It would be easy to evade the topic with Mrs. Raymond in this particular moment because of the way she raised it, but what if the next patient asks about his wife? He must prepare for the future. Ideally, a physician planning to practice in a close-knit town—particularly a conservative one—would prepare for questions like, “Are you married?” to avoid having to make on-the-spot decisions. It also may be wise to investigate the general atmosphere of a town and consider it before relocating there.

Dr. James’s decision to disclose his sexual orientation is a personal, subjective, and complicated one with risks and benefits that only he can weigh. He must ask himself the following questions—and maybe others:

• Who knows he’s gay? Does his business partner know? Other people in town? (The implication seems to be that nobody knows, but maybe Dr. James’s personal friends do.)
• Does he want Mrs. Raymond to know? (He must weigh her potential reaction in the moment.)
• Does he want other people to know? (He can’t expect her not to tell anyone.)
• Can he stand to lose her as a patient?
• Can he stand to lose other patients?
• How would his practice partner react? Could he lose his practice altogether?
• Has he lied to or misled people in Cedar about his personal life (e.g., putting a picture of a woman on his desk)—which would endanger his credibility if or when he decided to come out—or has he merely been private about his personal life?
• Is he ready to deal with the worst-case potential fallout? (Loss of job, social ostracism, and so on.)
• Is he in a relationship with anyone? If so, is the partner eager to be acknowledged or does he desire to keep the relationship private or are they ambivalent? What are the stressors on that relationship from being closeted? Furthermore, do they live together? How is that cohabitation publicly acknowledged? (“Roommates”?)
• Are there other gay folks in town who would benefit from having a respected professional authority in town come out?—including gay patients, who he may or may not know about and who might benefit (generally or in terms of health behavior) from knowing their physician is gay? Does Dr. James have an obligation to any degree to advocate for other gay people?
• Is he putting himself or any partners or friends in physical danger by coming out? (i.e., how violently homophobic can things get in this town?) Are there any measures he can take before or after coming out to protect himself and others, if need be?
• How long was he originally planning on living and practicing in Cedar? Is he building a life there? Just toughing out a few years before seeking to practice somewhere else? Could he live in another town but keep his practice in Cedar?

Dr. James should come out “whenever and wherever it feels safe…lesbian, gay, and bisexual physicians join others in the workplace in the casual, honest conversations that pertain to career, family, and personal choices” [10]. From what others quoted here have said, it seems best that Dr. James not create a deception that he then must remember and add to, ultimately risking all credibility if he later decides to change his personal story. Dr. James has more work to do in discovering what he wants for himself in the long term—but coming out is not a destination. It’s a process; it will happen repeatedly throughout his personal and professional life, and all of the factors discussed above will be in play each time it does, but each situation is different. It is probably best to be consistent, but more important to take into account his safety in each circumstance.