AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. August 2010, Volume 12, Number 8: 606-607.

From the Editor

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Politics, Religion, and Sex—Social, Legal, and Medical Equality for LGBTQI Americans

Introduction to the August 2010 issue of Virtual Mentor on the topic of sexual orientation, gender identification, and patient care.

Human sexuality and sexual behavior have long been a focus of research and debate, eliciting controversy within the academic, political, and religious communities. From Alfred Kinsey’s work in the 1930s and 40s, to the Diagnostic and Statistical Manual of Mental Disorders categorization of homosexual behavior as pathologic in the 1960s, to the codified homophobia which led to Lawrence v. Texas in 2003, people engaging in sexual behavior considered outside the heterosexual “norm” have faced misunderstanding, discrimination, and hostility. The medical profession is by no means insulated from shifting societal norms and perceptions regarding the LGBTQI (lesbian, gay, bisexual, transgender, queer, questioning, and intersex) community. It is difficult to imagine that any physician would encourage or perpetuate overt bias, yet the unique needs of the LGBTQI community are often neglected.

One reason for this may be a general discomfort surrounding sex-related topics. Physicians and other medical professionals routinely inquire, without trepidation, into intensely personal, delicate matters—death and suicide, intravenous drug use, bodily functions—but somehow the age-old maxim that one should “avoid politics, religion and sex” in polite conversation seems to hold true even within the clinical relationship. But it may be easier to raise such topics than we assume. When a group of teens was asked how clinicians could best facilitate discussions with them about sex and sexual orientation, the overwhelming response was: “All you have to do is ask.”

Why should we ask? Why do we need to know? Though of course sex-related matters are important to discuss with all patients, regardless of orientation, it is particularly crucial that we bring up these topics for the benefit of LGBTQI patients. The ostracism and marginalization of many LGBTQI patients within the community may make the physician’s office one of the only forums in which they can voice their medical and social needs. Many LGBTQI adolescents face threats of homelessness and bullying upon coming out; ultimately, they are at higher risk for substance abuse, depression, and suicide. The clinical setting should be a safe haven where those concerns are competently and compassionately addressed, not silenced or compounded.

Clinicians must also be familiar with risks specific to LGBTQI populations and know what screening and counseling is appropriate for the individual patient. For instance, if a physician assumes that a lesbian patient is heterosexual and counsels her about HPV transmission in the context of heterosexual activity, the lesbian patient might assume that HPV cervical cancer screening—not to mention annual gynecologic exams—do not apply to her. This assumption may well put her health at risk.

In addition to being informed about the sexual and mental health of LGBTQI patients, clinicians must also be aware of the inequities in the medical setting itself. LGBT patients—particularly those in the military—may encounter certain legal barriers that their heterosexual counterparts do not face. Physicians should be informed about such sensitive issues as accepted surrogates for end-of-life decision-making, reproductive and visitation rights, and child custody concerns.

Finally, we must consider the frequently overlooked needs of LGBTQI health care professionals. Lesbian, gay, and bisexual physicians and other health care professionals may feel that nondisclosure of their sexual orientations to their colleagues and peers is the safest course of action when a pervasive assumption of heterosexuality exists. While no LGBTQI person should feel compelled to out himself or herself, if and when a person wishes to share that integral part of his or her identity, he or she should be able to do so in a safe, supportive environment, without negative repercussions or ostracism.

Even more important than medicine’s awareness of LGBTQI issues is communication between patients and their physicians. Understanding patients’ sexuality—like compassionately acknowledging race, culture, and socioeconomic status—allows medical professionals to treat the complete patient. In this issue of Virtual Mentor, we hope to provide health care professionals with the information, tools, and resources they need to talk about sexuality with all patients.



Jackie Landess, MD, JD PGYResident PGY-1, Psychiatry McGaw Medical Center of Northwestern University Chicago, Illinois

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