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A Fear Worse Than Death

Sklar, David P., MD

doi: 10.1097/ACM.0000000000000696
From the Editor

Editor’s Note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members.

When I walked into the examination room, I recognized the man sitting in the chair. He was Joe, the janitor (name and identifying features changed). We often spent nights chatting in the resuscitation room, when all the students and residents were gone, while I typed notes about the last case and he cleaned blood from the floor to be ready for the next patient. Joe took his responsibilities very seriously and never complained no matter how horrific the mess. He had a hopeful, cheerful expression on his face most of the time, his mouth and moustache in a perpetual smile, but on this day there were frown lines on his forehead when I greeted him. “What’s going on, Joe?” I asked as I approached him.

“Needlestick,” he said. “The nurses sent me down here to be checked out.” He had punctured his hand with a needle while cleaning up on the Medicine ward. Because it was after hours for our employee health clinic, he had been sent down to the emergency department for his evaluation. The doctors and nurses on the ward thought they knew the source of the blood on the needle and were trying to verify the patient’s HIV and hepatitis status. “They were worried about AIDS,” Joe explained to me.

“Joe,” I said, trying to reassure him, “Most likely the patient does not have the virus that causes AIDS, and the tests will probably be negative. Even if the patient had the virus, the chances you would become infected are very, very low, and in any case we could give you some medicine that would prevent the possibility of AIDS. Don’t worry. It will just take some time to get all the information we need. Have you cleaned up your hand?”

“Yes, I scrubbed it with bleach and soap and water. The nurses upstairs helped me.” He showed me his very clean, deeply calloused hand with the tiny puncture in the palm.

“Boy, I can hardly see anything,” I said, “You really cleaned the heck out of it.”

“Well, I know a lot about cleaning.”

“Don’t worry. I have never had anyone get an infection from a needlestick in all my years here,” I said.

“What I’m worried about isn’t getting AIDS or even dying of AIDS,” he said. “I can handle that. It’s that everyone will think that I am gay.”

“Joe, that makes no sense. First of all, you are not going to get AIDS, but why would you worry more about people thinking you were gay than dying of AIDS?”

“Because where I live, if they think you’re gay, you might as well be dead.”

I went out of the room to call the Medicine floor and try and resolve the questions about the needlestick. Fortunately, the nursing supervisor had good news. The donor patient was HIV negative and was also low risk for hepatitis or any other blood-borne diseases.

I told Joe the news and he let out a deep sigh of relief and a big smile broke out on his face. He came over and gave me a hug and asked if he could go back to work. “Let me just finish the paperwork,” I said. “We have to follow the guidelines, and they change every few months. And the paperwork takes longer than the actual medical care.”

As I wrote up his chart, I realized that although I had been acquainted with Joe for at least 10 years, I knew very little about his life, his family, his community, and what he worried about. It was unimaginable to me that anyone would be more frightened of being seen as gay than to have AIDS, much less to die of AIDS. I suppose I was influenced by the enormous shift in attitudes about lesbian, gay, bisexual, and transgender (LGBT) populations. The Pew Research Global Attitudes Project1 has documented the changing attitudes about homosexuality in the United States and in 38 other countries around the world. In the United States in 2013, 60% of the public felt that homosexuality should be accepted, an 11% increase since 2007. In Canada, Spain, and Germany, acceptance rates were 80% or higher. However, this study also documented that in some parts of the world, such as Kenya, Uganda, Nigeria, Indonesia, Malaysia, and Egypt, acceptance was very low, less than 10%. The differences were striking. In this study, the importance of religion in the culture of the country appeared to correlate with lack of acceptance of homosexuality. There were also substantial differences in attitudes based on age, with people 18 to 29 being more accepting of homosexuality than those 50 and older. Clearly, Joe came from a background and community that continued to have strongly negative attitudes about homosexuality.

Attitudes such as Joe’s are, unfortunately, still not rare, and they can have deleterious effects on LGBT health care providers and patients. What can we do to change such attitudes? There is evidence that many forms of prejudice, including negative attitudes about homosexuality, can be reduced by increasing contact between majority and minority individuals.2,3 The current issue of Academic Medicine presents three reports,4–6 a Commentary,7 and a Perspective8 that update some of the research related to LGBT health issues and discuss their implications for medical education. After describing these five pieces, I will present some suggestions about how academic health centers can improve the environment for the LGBT community’s students, staff, faculty, and patients, and in doing so can also improve the environment for all of our learners, providers, and patients.

In one of the reports, Przedworski et al4 surveyed matriculating students from 49 medical schools and noted that sexual minority students (i.e., all those who, in their study, indicated they were not heterosexual) were more likely to report harassment and social isolation than were their heterosexual counterparts. The sexual minority students also reported higher rates of depression, anxiety, and poor overall health. While in this study it was not possible to connect the occurrence of harassment to mental health problems, the Institute of Medicine, in a report on national LGBT health issues,9 noted the association of sexual discrimination and victimization with a risk for mood disorders, anxiety, depression, and suicidal ideation in several LGBT populations. These two reports should help raise awareness about the need to examine our institutional environments and make needed changes.

In another report, Burke et al5 queried self-identified heterosexual first-year medical students at 49 medical schools about their attitudes toward lesbian women and gay men. They found that greater frequency of and certain types of more positive contact with gay and lesbian individuals were associated with more positive explicit and implicit attitudes toward gay and lesbian individuals.

In a separate study, Mansh et al6 investigated the issue of disclosure of sexual and gender minority (SGM) status (usually defined as LGBT status) among medical students. These authors found that 29.5% of the sexual minority students and 60.0% of the gender minority students in their sample did not disclose their SGM status, citing this as a private decision or describing fears of discrimination in medical school, lack of support, or loss of opportunities for matching in certain residencies. Students from the southern or central regions of the United States were less likely to disclose their SGM status than were those from the Northeast.

In her Commentary, Fallin-Bennett7 urges further investigation about communication and disclosure of LGBT status to improve the quality of medical care provided to LGBT populations. It would seem that, again, the type of institutional environments we maintain and the openness to differences would be areas for continued attention and improvement.

In a Perspective, Mansh et al8 provide the historical context for current efforts to improve conditions for LGBT individuals and remind us that while the role of the psychiatry community in removing homosexuality from its classification of psychiatric diseases was a critical moment for encouraging changes in attitudes toward LGBT individuals, the prior years of pathologizing homosexuality as a psychiatric disorder did much damage. The authors also encourage self-disclosure as part of an overall approach to improving workforce diversity, recruitment, inclusion, and support.

What else can we learn from these five contributions to the May issue? I will focus on three areas.

First, the history of attitudes toward LGBT individuals demonstrates the important role that medical experts can play in supporting or harming the health of various populations, whether they are identified by race, ethnicity, culture, disability, political views, gender, or SGM status. The history of the classification of homosexuality as a mental illness is a reminder for us to be ever vigilant in not abusing the trust and confidence of the public in providing our medical opinions. We should be certain that our pronouncements are based on valid evidence, particularly when the consequences of unfounded statements could stigmatize a group of patients.

Second, the environment of care involves the exchange of private information between patients and providers. Such exchange requires trust and truthful disclosures that are possible only if patients can be confident that their information will be received in a professional and nonjudgmental manner. An environment of tolerance and acceptance of difference that allows students, staff, faculty, and patients to be honest about issues such as SGM status can create the opportunity for disclosure of other types of sensitive and private information. Establishing a supportive environment for all aspects of diversity should be a goal for our health care environment, yet this is clearly not yet the case. As one of the participants in Mansh and colleagues’6 study noted:

Medical school is incredibly intense, and we barely receive any support in handling the stress (especially in the clinical years when we deal with issues including evaluations, competition, and becoming immersed in clinical situations we cannot control, i.e., the death of a patient). Throughout this intensity, I have become more and more distanced from the friends and relationships that offered me so much support in college. I feel that there could not be any worse … time to come out or even question my sexuality.

Those of us who are faculty must recognize our responsibilities to assist our students in the development of both their professional and personal identities, and strive to create support for them.

Finally, while many of the challenges for LGBT individuals have related to attitudes, there are also elements that relate to knowledge and skills. Fortunately, there are new resources that have become available that fill gaps in knowledge and skills. The Advisory Committee on Sexual Orientation, Gender Identity and Sex Development of the Association of American Medical Colleges has recently published a book10 about implementing curricular and institutional climate changes to improve health care for individuals who identify as LGBT or gender nonconforming, or were born with differences of sex development. At the same time, the Institute of Medicine’s report,9 mentioned earlier, addresses the research needs of LGBT health. Together, these documents can help fill the gaps in information and skills in education and research methodology that currently exist. In addition, a recent article by Callahan et al11 in our journal describes the efforts to improve documentation of information about LGBT status in the electronic medical record at the University of California, Davis, School of Medicine as a way to improve the quality of care for LGBT patients. While this initiative improved the documentation of information, the process of institutional decision making also created more positive attitudes about the value of LGBT information in the medical record.

I hope that the ongoing changes in attitudes about LGBT populations continue to promote understanding, acceptance, and, ultimately, awareness of the important contributions that a tolerant and accepting environment can make to support a diverse health care environment. However, progress does not always develop in a linear fashion. That is why it is important that the medical education community continue to provide leadership and support for our LGBT students, faculty, and patients regardless of the potential consequences. I never want to hear another of my patients tell me that he would rather die than be seen as gay. Nor do I want to encounter another LGBT young person in the emergency department who has attempted suicide because of depression from bullying and lack of acceptance from friends and family. I hope that through the publication of articles such as these in this issue of Academic Medicine, we can contribute to the growing awareness of LGBT health and medical education issues, have more conversations on these topics at all of our academic health centers, and foster an environment more accepting and open toward diversity in all its many shapes and colors.

David P. Sklar, MD

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1. Pew Research Center. . The Global Divide on Homosexuality. 2013 Accessed January 6, 2015
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© 2015 by the Association of American Medical Colleges