Originally published in Synapse on October 22, 1998.
Last week, the country confronted the death of Matthew Shepard, the University of Wyoming student killed in a vicious, antigay hate crime. This tragedy raises important issues for current and future healthcare providers. Homophobia, and its resulting bigotry and violence, concern all clinicians. Skeptics argue that homophobia is a “special issue” affecting a tiny minority of patients and has no relevance to the hands-on work of medicine.
Among their arguments:
“Violence, anti-gay or not, is a problem for police or social workers, not healthcare workers.” In fact, the American Medical Association has dubbed violence an “unrelenting epidemic” in which “health care professionals are uniquely positioned to intervene” (JAMA, June 14, 1995; 273:1793).
Since announcing its initiative against violence in 1992, the AMA has published dozens of articles on topics such as how to address domestic violence against women, the role of guns in injury and death among urban youth, and the use of education to prevent violence among schoolchildren.
Violence is not just a primary care issue. In a 1995 “Position Paper on Violence Prevention,” the Surgical Section of the National Medical Association stated, “Without any prevention... or community outreach activities, trauma surgeons and surgical intensivists amount to glorified medics in an unwinnable war” (JAMA, June 14, 1995; 273:1788).
“While tragic and shocking, antigay crimes like the Shepard murder are rare.” Sadly, not true. In 1997, the National Coalition of Anti-Violence Programs (NCAVP) documented 2,445 incidents of anti-gay violence and harassment in 14 U.S. cities alone, a 25% increase over the previous year.
Since it applies to just part of the country, and most such events go unreported, the figure greatly underestimates the true scope of homophobia faced by lesbian, gay, bisexual, and transgender Americans.
More disturbing, the NCAVP survey showed a continued increase in anti-gay crimes despite a decrease in violent crime in the United States overall. This may be linked to the rise in public expressions of anti-gay feeling in general.
“None of my patients is gay, so addressing anti-gay prejudice doesn’t apply to me.” Actually, surveys repeatedly show that 4% to 10% of the U.S. population identifies as gay, bisexual, or transgender. This cuts across all age and racial groups. Still, even if none of your patients is gay, or none tells you she is gay, your presumably straight patients are affected.
First of all, the NCAVP survey found a growing trend in anti-gay crimes against straight people whose attackers thought they were gay. More to the point, homophobia in the general population gives rise to bigotry and violence. Health care workers have a role in educating to combat this.
“What do you mean? None of my patients is a gay basher.” One-third of male college students admit to verbally harassing people they thought were gay, and 18% admit to physically threatening or assaulting such people.
These figures, from a study of 500 San Francisco Bay Area community college students presented at the 1998 meeting of the American Psychology Association, add proof that harassment due to homophobia is far from rare. The figures for women were 24% and 10%, respectively.
Chillingly, half the students said they’d repeat their behavior. Dr. Karen Frank, author of the study, commented, “The reason they don’t see anything wrong is simple — no one is telling them it is wrong.”
An anecdote illustrates this point. Jim Barnes, who killed a gay man in Bangor, Maine, 14 years ago, later told the Washington Post, “It was a common practice among youths... to pick on homosexual people. I had no one to ask questions about homosexuality, and no one to teach me that it is a part of life.” Barnes, who committed his crime at the age of 15, threw his victim, Charlie Howard, off a bridge.
“Well, how am I supposed to bring up this topic? It’s hardly something I can work into my regular physical exam.” Actually, you can. It can be as simple as starting your sexual history-taking with the question, “Has your sexual history included sex with men, women, or both?”
“What if my patient gets angry when I ask this?” Tell him you ask all your patients this question and that a doctor needs to know about a patient’s sexual orientation and activity in order to care for her properly.
This method may give patients with questions about homosexuality a chance to voice them to a neutral provider who can dispel misconceptions. It also creates a “safe space” for patients who are gay, or who engage in same-sex behavior, to bring it up.
“But I don’t think a patient’s homosexuality has any relevance to medical care.” Actually, studies show gays and lesbians have higher risks for overt medical problems such as HIV and breast cancer, as well as higher rates of health-related factors like drug and alcohol abuse and obesity.
The Journal of the Gay and Lesbian Medical Association, founded two years ago, has become a forum for publishing such research. Health concerns may be even greater for patients who are “closeted” about their sexuality or do not identify as gay, such as men in heterosexual marriages who engage in clandestine, same-sex activity.
A UCSF study presented at the 1998 International AIDS Conference showed that men who do not identify positively as homosexual are at greater risk of HIV infection compared to men who do.
“I work with children, so none of this applies to me.” Again, quite the opposite — gay youth are the population most in need of outreach. For example, one study estimated that nearly one-third of teen suicides resulted from struggles around sexual orientation.
A friend of mine once told his pediatrician, “I have a problem. I’m gay.” His doctor replied, “Why should that be a problem?” Ah, isn’t it pretty to think so! By blithely dismissing his patient’s real concerns, such as how to come out to his family or learning about safer sex (gay men under 25 comprise a huge portion of new HIV infections), this doctor may have done more harm than good. Also, since teens are among the worst offenders in anti-gay acts, their health providers have a key role in educating them to prevent such violence.
“This doesn’t happen here.” Even in the “enlightened” city of San Francisco, where 30% of the electorate is estimated to be gay, homophobia and its effects are felt. Just last year, for example, a San Francisco man was killed in a hate crime outside a Folsom Street bar. It happens here. It happens in Wyoming. It happens everywhere. It is everyone’s concern, and healthcare practitioners have a special role in stopping it.
I hope the UCSF community takes this message to heart and spreads it to all their future communities and institutions. Change comes with agonizing slowness, but without it. Matt Shepard will be just another martyr in an endless series of preventable tragedies.
