By Sarah Ellerman
Illustration by Malcolm Garris/PhotoDisc
January 7, 1999

Many patients are reluctant to open up to their healthcare providers, and for gay and lesbian patients it can be even harder. In addition to bearing a higher-than-average risk for some diseases, these patients often feel rejected by the very people charged with safeguarding their health.

"To me, the primary healthcare issue [for gay and lesbian patients] is one of homophobia," said Margaret Miller, RN, head of the National Lesbian and Gay Nurses Association. Facing the disapproval of authority figures such as healthcare workers can be so intimidating that many gay patients neglect their own care, health experts say.

Unique needs

Gay and lesbian patients often have special healthcare needs. In particular, lesbians tend to have less money and less access to care than other patients, Miller said. The fact that this makes them less likely to seek health care is tragic because lesbian women may run a greater risk of contracting breast cancer, said Suzanne Dibble, DNSc, RN, associate adjunct professor at the Institute for Health and Aging at the University of California, San Francisco.

In a recent study comparing breast cancer rates of women of different sexual orientations, "lesbians had more breast biopsies than did heterosexual women, after controlling for all variables," said Dibble, adding that further research will be required to discover whether the discrepancies are due to differences in nulliparity or in access to care.

In addition, lesbian women often skip gynecological exams, said Michael Venator, RN, clinical director of Montrose Clinic in Houston, which does outreach to the gay community. Because they are not motivated by contraceptive needs to see healthcare providers, these patients may miss out on Pap smears and STD screenings. To help combat this, Montrose Clinic sponsors special well-woman exams outside of a family-planning scenario.

Gay men also have unique health risks, say healthcare experts. In addition to the prevalence of HIV, men who participate in anal-receptive sex are more likely to have intestinal infections and rectal cancer.

In addition to these conditions, gay men and women have a higher-than-average prevalence of depression, which healthcare experts often attribute to societal disapproval and internalized shame.

Identity vs. behavior

It’s important to remember that sexual identity and sexual behavior are often very different issues, expert says. Sometimes, gay people still have sex with members of the opposite sex, and many straight people dabble in gay relationships. In fact, many of Venator’s clients are "straight" men who have come to the clinic only after weeks of suffering with an STD contracted during sex with another man, he said. Their own homophobia has led them to anonymous encounters and unsafe sex, perpetuated by a belief that "I’m really straight, so I’m not going to get anything," Venator said.

Because many patients are in denial about their sexuality, it is crucial that nurses ask patients specific questions to elicit information. "It’s very difficult," Dibble said. "If you’re doing a health history, you have to ask two questions. One is how you identify, and one is the behavior question."

Improving care

There are steps that nurses can take to maintain an inclusive environment. "The main thing is just to be accepting and nonjudgmental," said Venator, who advised other nurses to focus on healing and educating patients instead of judging their behavior.

One basic improvement is altering questionnaires, which are patients’ first impression of a provider. Directly ask patients about their sexual orientation, Venator said. Under status, allow them choices other than simply "married" or "single," such as "domestic partnership."

And if you really want to make a commitment to a gay-friendly practice, allow same-sex partners to participate in care and decisions the same way that spouses can, suggests Miller. For instance, if a husband is encouraged to participate in discussions about cancer treatment options for his wife, make sure that your lesbian patients know that their partners are equally welcome.

In the end, making gay patients feel comfortable and safe simply means using strong nursing skills and being compassionate, Miller said.

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