The middle-aged patient with long dark hair made it very clear that this was not her first urinary tract infection. “It’s because when I urinate,” she said, “I need to use a catheter.” She opened the leather satchel on her lap and, to prove her point, pulled out a thin, red sterile length of tube covered in plastic.
“Just ask one of the older nurses or doctors,” she said, smiling. “They all know me.”
But as I would learn, it was not because of her recurrent infections that so many of my colleagues knew her. Several years earlier, she had come in for a routine operation. The doctor had evaluated her before the operation, learned that she was a homemaker and met her husband. But on the morning of her operation, as he pulled down the sheets to begin inserting the urinary catheter into his now sleeping patient, he was startled to discover that the patient was not exactly who he had assumed she was.
She was transgender, and where he had been expecting to find female genitalia, he found male genitals instead.
The operation had gone well; but years later the doctor’s glaring oversight continued to haunt the rest of us. The patient had obviously not felt comfortable disclosing her transgender identify, and the doctor had clearly not asked the right questions. We knew that any one of us could have made the same mistake. While we had been trained well in treating cancer with the best chemotherapy regimen, curing flesh-eating infections with the most powerful antibiotics or transplanting organs with the greatest of ease, when it came to caring for patients who were transgender, we were lost. For many of us, the same could be said for lesbian, gay and bisexual patients as well. The only thing most of us knew how to do was ask about a single issue: “Whom are you having sex with? Men, women or both?”
A study published recently in The Journal of the American Medical Association shows that the situation has not changed much for young doctors. Researchers from the Lesbian, Gay, Bisexual and Transgender Medical Education Research Group at Stanford University School of Medicine surveyed medical school deans in the United States and Canada and asked about the curriculum devoted to topics like gender identity, coming out as gay and disparities in health care access for lesbian, gay, bisexual and transgender patients. While nearly all the students were learning to ask patients about the gender of their sexual partners, a majority of medical schools devoted only five hours to teaching anything more than that simple question. Fully one-third of schools allotted no time at all.
“These results should serve as a call to action for the health profession to include L.G.B.T. health as part of the standard curriculum,” said Dr. Desiray Bailey, an anesthesiologist and president of the Gay and Lesbian Medical Association.
What little training medical students do receive — focusing on sexual behavior or H.I.V. infections — ignores the many other complex health-related issues these patients often deal with. As documented in a report issued this year by the Institute of Medicine, L.G.B.T. patients tend to be more isolated and have higher rates of chronic diseases like diabetes and high blood pressure. And because of the discrimination they face and fear, many also have difficulty gaining access to care and thus face an increased risk of suicide, substance abuse and unaddressed domestic violence.
Just “seeing the doctor” can be fraught with tension, as it entails coming out to one’s physician.
“These patients need to feel that they can tell their doctor they are gay and that their doctor will accept them,” said Dr. Mitchell R. Lunn, senior author of the study and a resident in internal medicine at Brigham and Women’s Hospital in Boston.
But while the federal government has recently announced several initiatives to address disparities in L.G.B.T. health care access, the study confirms that most medical schools are lagging behind. Those schools that do integrate the material into standing courses, offering electives or inviting outside experts to speak on topics like gay parenthood, lesbians’ health or the use of hormones in transitioning from one gender to the other. At other schools, medical students can discuss sexual identity issues with actors who have been trained to play the part, asking them whether they feel different from the identity assigned by society at birth, for example, which helps the students to eventually discuss these topics with real patients in a nonjudgmental but confident way.
But it’s unlikely that most medical schools will change how they teach medical students anytime soon. Organizations responsible for accrediting medical schools and licensing physicians do not require that prospective doctors know about health care issues for lesbian, gay, bisexual or transgender patients. And because research in this area is relatively new, it’s difficult for medical schools to find experts qualified to teach.
Nonetheless, many still view the study results as hopeful because of the level of insight from most of the medical school deans. More than a quarter characterized what their school taught in regards to L.G.B.T. patients as “poor” or “very poor,” and almost half called their offerings only “fair.” “This honest appraisal gives me hope that they might already be making plans to improve what they teach,” Dr. Bailey said.
And those kinds of improvements, the study authors believe, would benefit all patients.
“This is about being a good doctor, because a trusting relationship is not just about a patient’s physical or even mental well-being,” Dr. Lunn said. “It’s about learning who that patient is.”