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Beyond inclusion

Garel, Ali

Journal of the American Academy of Physician Assistants: April 2017 - Volume 30 - Issue 4 - p 1–2
doi: 10.1097/01.JAA.0000513356.91265.d2
Becoming a PA

Ali Garel is a second-year student in the PA program at Wake Forest School of Medicine in Winston-Salem, N.C.

Tanya Gregory, PhD, department editor

My first year in PA school rather effectively taught me how much gray exists in medicine. Our bodies aren't always predictable machines. We can't always bank on pushing a specific button to get a certain result. We are fine works of art. We are intricate. We are body, but we would be nothing without mind, emotion, love, and spirit. To me, medicine represents an intersection between puzzling over physical science while lovingly interacting with soulful individuals. As a PA student, I've spent an inordinate amount of time obsessing over the science—fighting, sometimes in vain, to understand hepatorenal syndrome, or the ovarian cycle, or pharmaceutical BP—struggling to remember that the real reason I ever decided to walk down this road toward medical practice was to work with people. I want to provide physical care, but also to provide an emotionally safe space for people, for all people, to seek health and well-being. I thought that is what all aspiring and practicing providers aimed to do.

Last year, this view was challenged. The Christian Medical & Dental Associations (CMDA), an organization with a large constituency in my region, released two ethics statements about LGBTQ identification.1,2 Although arguably attempting to be inclusive, the statements include many details that are discriminatory, hurtful, and potentially dangerous. It scares me that healthcare providers are being encouraged to practice medicine, practice the art of caring for fellow human beings, in a discriminatory manner.

The statements profess the dangers and reversibility of same-sex attractions and thus discourage acceptance of an individual for who he/she/ze/they innately are. For example, one ethics statement asserts that “deciding on a same-sex lifestyle and pursuing same-sex fantasies and encounters are voluntary and involve moral responsibility.”1 This type of thought process inherently promotes closed-mindedness and condescension while ignoring the biologic basis of sexual and romantic attraction. Subsequently these teachings minimize the love and commitment shared by same-sex couples. Later in the statement, the authors assert that “homosexual relationships are typically brief and successive,” propagating antiquated and stereotypical views of homosexuality, such as the incorrect assertion that gay couples cannot maintain long-lasting and committed relationships.

When the CMDA statement says, “Approval of same-sex marriage is harmful to the stability of society, the rearing of children, and the institution of marriage,” it bolsters the misconception that children raised by homosexual parents face disadvantages and thus discourages medical support for couples seeking fertility services or adoptions. This contentious subject has been a topic of debate for years and was assessed by Columbia Law School in 2016.3 Its overview found four studies citing disadvantage to children reared in same-sex households and 74 studies that found no difference in outcomes between children raised by opposite-sex versus gay or lesbian parents.3 Notably, in the four studies showing negative outcomes, most subjects were raised by opposite-sex parents for a period of time before one parent came out as gay or lesbian and left the relationship. The trauma inflicted on a child by the disruption of family stability clearly introduces a new, and unaddressed, variable to those studies. Research of this type is challenging because it requires doing large longitudinal studies; however, after reviewing the 78 cited peer-reviewed papers, the Columbia overview found that an “overwhelming scholarly consensus, based on over three decades of peer-reviewed research, that having a gay or lesbian parent does not harm children.”3

Furthermore, the CMDA statements make reference to adverse health consequences associated with being LGBTQ, such as elevated rates of substance abuse. It is simplistic to imply that substance abuse and its concurrent increased medical costs to society at large can be controlled by discouraging nonheteronormative sexual attractions. Instead, the complexity of substance abuse and lack of societal acceptance for LGBTQ people must be considered contributing factors in a multifaceted disease.

These statements come at a trying time in the local LGBTQ community. North Carolina, where I attend PA school, passed House Bill 2 last year. This piece of legislation blocks antidiscrimination laws aimed to protect LGBTQ people and makes it illegal for transgender people to use the restroom belonging to the gender with which they identify. Under the guise of promoting public safety, such a law creates a physically dangerous situation for transgender persons and a legally dangerous situation for other LGBTQ persons. Political statements such as these propagate fear in a community that is already ostracized, making openness, even in the pursuit of healthcare, a daunting prospect. It is no secret that LGBTQ persons already face large disparities in access to healthcare and health outcomes. LGBTQ persons are more likely than heterosexual peers to report difficulty seeking care, to face violence, to be obese, to struggle with substance abuse, to experience psychologic distress, to have suicidal ideations, and even to develop certain cancers.4 Poor understanding of necessary preventive care contributes to some of these disparities, but how many of them originate in fear and distrust? Stigmatization makes it difficult to find a truly safe space to open up, and if healthcare providers, both aspiring and practicing, should be anything at all, we should be a safe space. We should provide an environment for people from all walks of life to be truthful, in the name of seeking both physical and emotional health and well-being.

Many healthcare providers do provide a warm, safe space. In fact, the American Medical Association's (AMA) inclusion policies expressly recognize healthcare disparities in LGBTQ communities and encourage a “cooperative effort between the physician and the patient” to allow for openness in communication and provision of adequate preventive screenings and resources for LGBTQ patients.5 Nonetheless, that even one group of healthcare providers encourages discriminatory policies is one group too many.

I understand that my views are by no means universal. I understand that this is a contentious subject fueled by politics, religion, and tradition. I also understand that the LGBTQ community is by no means the only group facing discrimination and adverse health outcomes. Similar concerns exist for racial, ethnic, and religious minorities. What I aim to convey is that discriminatory politics, judgments about sexual orientation, and repression of marginalized groups do not belong in medicine. I am a student, and I realize my view is likely idealized and potentially naïve. Nevertheless, realizing that overt homophobia is alive and real among medical providers and students shakes my core understanding of the meaning and purpose of providing healthcare. I want to challenge my peers not only to embrace the notion that “we are all the same” but to push beyond it. I challenge healthcare providers in training and in practice to strive not just to see all people as equal, but to see every human we interact with as exceptionally unique—not just to tolerate differences, but to embrace individuality and yet still treat our patients equitably.

Early on in PA school, I sat in my university chapel, surrounded by my classmates, at our white coat ceremony. Leaving the event, I found myself thinking about the Hippocratic Oath. One line in particular stands out to me: “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.” May that same warmth, sympathy, and understanding allow providers to toss aside preconceived notions, political or religious agendas, and implicit biases so that we all, students and seasoned providers alike, can aim to embrace our patients as individuals seeking the thing we are all aiming to provide: physical and emotional health and safety.

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1. Christian Medical & Dental Associations. Homosexuality ethics statement. Accessed December 20, 2016.
2. Christian Medical & Dental Associations. Transgender identification ethics statement. Accessed December 20, 2016.
3. Columbia Law School. What We Know: The Public Policy Research Portal. What does scholarly research say about the wellbeing of children with gay or lesbian parents? Accessed December 20, 2016.
4. Health Resources and Services Administration. Health equity for diverse populations. Lesbian gay bisexual transgender. https:// Accessed December 20, 2016.
5. American Medical Association. Policies on lesbian, gay, bisexual, transgender, & queer issues. https:// Accessed December 20, 2016.
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