“A 31 year-old homosexual man…” the practice question stem begins. I jump to
the end of the long paragraph of details, ending with “What is the most likely diagnosis?”
Of the answer options, one is related to HIV; I choose that selection. I am correct. On to
the next question.
Whenever specific descriptors are added to a patient vignette for board exams, it
is grounded in higher prevalence of certain diseases, behaviors, or traits. On the one hand,
understanding epidemiology is important, but on the other hand, the reinforcement of
these associations also enhances stereotypes, which can dangerously narrow the
differential diagnosis based on these descriptors of sexuality, race, ethnicity, and country
of origin.
I have lost track of the number of practice questions that I have encountered
which begin with a “homosexual man,” for which the answer is—without fail—HIV or
it's sequelae. I have never encountered a question involving a gay man with any other
diagnosis. On questions pertaining to sexually active heterosexual individuals, the answer
has yet to be HIV. And, as a queer woman, I have yet to see someone sharing my identity
as a patient in a practice question, let alone any sexual orientation or gender identity
(SOGI) minority represented apart from gay men. These questions, meant to represent
students’ knowledge and ability to manage patient interactions, does not reflect the
diversity of LGBTQI+ patients, and instead pigeonholes gay men into one (stigmatized)
identity: a person living with HIV. I was frustrated with this portrayal, and frustrated that
this is all we are expected to know.
And this frustrating representation has been reflected in my experience in
healthcare, and that of my friends. I have heard directly how the views reinforced by such
practice questions translate into clinical practice: my friends who are men who have sex
with men (MSM) report being asked right off the bat if they have HIV, which I have
never been asked, regardless of whether it is relevant to their care. While it is true that
MSM have the highest HIV burden, followed by heterosexual African American women
and then people who use IV drugs (1) , the way these questions are consistently framed such
that only gay men have HIV and HIV is only found in gay men does more to reinforce
bias than to teach disease epidemiology.
This teaching is extremely damaging to gay men. And on the flip-side, it
obliterates the recognition of the unique health needs of queer patients who are not gay
men. In my experience, I “pass” as straight: that is to say that the way I dress and behave
does not match the stereotypical picture that people have of gay women, and so the
assumption that I am straight follows. And it follows me to every doctor’s appointment. I
am met with the line of questioning “Are you sexually active? Are you on birth control?
Do you use condoms?” It is inconceivable (pun intended) to the questioner that I could
not be at risk for pregnancy if I am not abstinent. I am often met with “You know, use of
some form of birth control, like The Pill, and condoms are the best way to avoid getting
pregnant.” I think that I am doing a good job of avoiding pregnancy… This is one of
many scenarios that highlights why asking about sexual behavior and partners is paramount to one’s health—and this one is quite benign given the spectrum of possible
lines of inquiry by health professionals who have been taught that “gay = HIV.”
But how do I respond in these situations? This could be a teaching moment if I
felt safe and empowered to do so. Usually I am the recipient of the line of standard
patient sexual health education, in which I smile and nod, keeping my identity secret to
avoid an uncomfortable (possibly unsafe) situation. Other times, this information is
shared with a judgmental tone of voice, occasionally with an eye roll thrown in for what
feels like extra panache, and I sit there dumbstruck, and still silent. Once I was asked
“How can you be so smart, but so stupid?” because it was established that I am a medical
student, and assumed that I was engaging in sexual behavior that could result in
pregnancy (and that I do not want to become pregnant).
Being assumed straight is a privilege; I do not have to worry that, right off the bat,
I will experience discrimination or refusal of care. But in a 2018 study from the Center
for American Progress, 8% of LGBQ patients reported being refused care based on their
actual or perceived sexual orientation, and 9% reported experiencing abusive language
from their healthcare professional based on their actual or perceived sexual orientation.
So, as a cisgender queer woman, there is a significant risk to my speaking out, but it is
relatively low, especially compared to trans patients, of which 29% report being refused
care on the basis of their gender identity and expression, and 21% report experiencing
abusive language. In fact, a 2015 US Transgender Survey found that nearly 1 in 4 trans
individuals report avoiding seeking health care when they needed it due to fear of
discrimination or mistreatment (2).
So when the opportunity presents itself, such as in a sexual history, where I can
correct the person taking my history, do I dare to willingly shed my privilege, opening
myself up to the opportunity of experiencing who-knows-what, or do I wear this false
identity as a shield?
One is easy. One is scary. As a medical student, I have been told time and again
the importance of a thorough and focused patient history. “Listen to your patient; he is
telling you the diagnosis” is the often quoted Dr. William Osler axiom that I have heard
excellent diagnosticians cite. Yet, I am faced with an internal battle of identities—a queer
patient who worries about being honest for fear of experiencing discrimination, but a
medical student who knows that sharing this information is important to provision of
appropriate care, and a trainee who is being taught through practice questions that “gay”
means a gay man, and a “homosexual man” means HIV—and I find myself experiencing
horrible cognitive dissonance.
From this dissonance emerged the question “Why am I not being taught better?”
Why am I not being taught to treat patients like me? Why am I not being taught the
affirmative language to welcome all sexual and gender minority (SGM)
identities—especially trans, non-binary, and gender-non-conforming individuals? We
must do better by our queer patients, and education is the place to start. Through
education, we can raise a generation of health professionals who are sensitive to the health needs specific to SGM patients, have the knowledge and competency to address
them, and the appropriate language and attitudes to create an inclusive environment.
This is where the fight starts.
1. Centers for Disease Control. “U.S. Statistics.” HIV.gov, 13 Mar. 2019,
www.hiv.gov/hiv-basics/overview/data-and-trends/statistics.
2. Mirza, Shabab Ahmed, and Caitlin Rooney. “Discrimination Prevents LGBTQ People
from Accessing Health Care.” Center for American Progress, 18 Jan. 2018,
www.americanprogress.org/issues/lgbt/news/2018/01/18/445130/discrimination-
prevents-lgbtq-people-accessing-health-care/.