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Rapid Responses: Rapid Responses published:
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Gender identity, stigmatization and clinical implications!
- Dr. Naseem A. Qureshi, MD, IMAPA, LMIPS (21 May 2004)
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"Considerable" numbers" and chaperones
- Trevor G Stammers (23 May 2004)
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Normal?
- Mark D Lawton (25 May 2004)
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Dealing with colleagues is still a challenge
- Dan Saunders (28 May 2004)
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A Second Bite
- David Hughes (1 June 2004)
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Dr. Naseem A. Qureshi, MD, IMAPA, LMIPS, Medical Director [A], Director, CME&R Postcode 2292, Buraidah Mental Health Hospital, Saudi Arabia
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Sir: I read with great interest a highly informative, qualitative, descriptive study by Riordan [1] and the accompanying editorial by David Huges [2]. Notably, this study describes special interactions, all are based on sexual (gendered) identity, of a special group of patients with a special group of physicians, nurses and other technical staff. Evidently, straight male patients usually like to consult straight male doctors but if straight female is available, no hassles at all either. Further, straight female patients usually prefer straight female physicians but if male doctor is available (and female doc. is unavailable), some of them may refuse consultations. These types of gender based physician-patient-consultation stereotypes of mutual respect and relief are constructed by sociocultural dynamics of people over many centuries around the world. Probably, similar stereotypes may be applied to this unique group of population. A gay patient usually likes gay physician, a lesbian patient likes more often lesbian physicians and likewise bisexual patient likes bisexual doctor for consultation. They also feel mutually benefitting and respect is pervasive and moreover no anxieties at all. As reflected by the editorial [2] and this paper [1], dilemmas related to ethics, medicolegal, transgendered issues, personal autonomy and privacy, professional information giving more often emerge when there are cross-gender consultations, i.e., gay patients encountering straight doc. and so on, though this unique group of physicians and consultees use a variety of "desexualizing strategies" and "passing" and "outing" mechanisms. This population of physicians and patients represents a social "minority" group, which has been stigmatized by "majority" of people since time immemorial. Certainly, history is suggestive of such socially unhealthy trends. Finally, there are many other important implications of this study: unfortunately doctors and patients are sustaining and pursuing stigma against themselves; this is the call of the modern time that we must deconstruct effectively these negative stereotypes against gays, lesbians and bisexuals, patients as well as physicians; equal opportunities in all spheres of life must be given to both straight and non-straight male and female individuals; destigmatizing campaigns may help in reducing hatred (this I have experienced whenever I tried to chat gays or lesbians online, MSN-communities), which is markedly evident in both group of peoples; and finally sexual relationships post-consultations with consultees must be avoided. Reference: 1. Daniel C Riordan. Interaction strategies of lesbian, gay, and bisexual healthcare practitioners in the clinical examination of patients: qualitative study.BMJ 2004 328: 1227-1229. 2. David Hughes. Disclosure of sexual preferences and lesbian, gay, and bisexual practitioners. BMJ 2004; 328: 1211-1212 Competing interests: I am a heterosexual. |
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Trevor G Stammers, Senior Tutor in General Practice St George's Hospital Medical School, London SW17 0RE
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Being a member of several minority groups myself, I know how comforting it can be to think that we never-the less constitute a large number of people. David Hughes’ enthusiasm for this tendency in his editorial on gay, lesbian and bisexual practitioners (1) however deserves to be put into context. He mentions first Kinsey’s (2) widely quoted “10% statistic”. Kinsey’s research has now been so thoroughly discredited as fraudulent (3), that it should be viewed as unreliable. The 2001 NATSAL study did indeed show that about 5% of both men and women had ever had a same –sex partnership in their lifetime but only 2.6% had done so in the past five years. (4) Hughes comments that the “existence of the Gay and Lesbian Association of Doctors and Dentists” in the UK and a similar body in the USA “implies that considerable numbers of professionals are involved". This is surely no more the case than the existence of the National Association for Research and Therapy of Homosexuality (5) implies that there are considerable numbers of psychiatrists and psychologists who believe that sexual orientation can be changed by appropriate therapy? This may or may not be true. The GMC has over 200 000 doctors registered to practice in the UK. Riordan’s paper in the same issue (6) states that 85% (n=318) of the members of GLADD had access to email. This suggests a total of around 374 members. Of course as Riordan states not all gay, lesbian and bisexual doctors and dentists will be members of GLADD. The numbers do seem to be modest, though even if the total of 16 interviewed by Riordan were the only doctors involved, their opinions and experiences are of interest and value. I am much more concerned by another of Hughes’ implications however than just the numbers of professionals involved. He also suggests that the practice of using chaperones for intimate examinations of the opposite sex “is based on cultural assumptions of heterosexuality” and therefore “many lesbian, gay and bisexual practitioners follow this practice despite the sense of irony that it engenders". I am not sure why a bisexual practitioner should find it ironic to use a chaperone when examining a patient of the opposite sex? However even for gay and lesbian doctors, the disclosure of homosexuality would surely not constitute a strong defence in law in the event of a complaint arising when a chaperone was not used? The 1994 national survey of sexual attitudes and lifestyles in Britain (7) found that substantial proportions of those reporting same-sex partners also reported opposite-sex partners. Of men who report ever having had a male sexual partner in their lifetime, 90.3 per cent also had a female sexual partner, and for women the equivalent was 95.8 per cent. Furthermore, both men and women who had more than ten opposite-gender partners are more likely to have also had a same-gender sexual partner, compared with men and women with only one opposite-sex partner. There is also a high prevalence of bisexual behaviour in surveys of homosexual men. The proportion of homosexual men reporting both male and female partners in a lifetime was between 58 and 61 per cent, and in the past year between 10 and 12 per cent. (8) I would suggest that the situation is far more complex that either Hughes or Riordan suggest and that the use of chaperones in intimate examinations of patients of the opposite sex is a wise precaution for all doctors whether bisexual, trans, gay or straight. 1. Hughes D Disclosure of sexual preferences and lesbian, gay and bisexual practitioners BMJ 2004 328 1211-2 2. Kinsey AC Pomeroy WB Martin CE Sexual Behaviour in the Human Male 1948 Philadelphia WB Saunders 3. Reisman JA Eichel EW Kinsey, Sex and Fraud 1990 Huntingdon House 4. Johnson AM Mercer CH Erens B et al Sexual Behaviour in Britain Lancet 2001 358 1835-42 5. www.narth.com 6. Riordan D Interaction strategies of lesbian, gay and bisexual healthcare practitioners in the clinical examination of patients: qualitative study BMJ 2004 328 1227-9 7. Wellings K, Field J, Johnson AM, Wadsworth J, eds. Sexual behaviour in Britain. London: Penguin, 1994 8. Boulton M, Weatherburn P. Literature review on bisexuality and HIV transmission. In: Wellings K, Field J, Johnson AM, Wadsworth J, eds. Sexual behaviour in Britain. London: Penguin, 1994. Competing interests: None declared |
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Mark D Lawton, SHO medicine Chester CH2 1UL
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I am shocked to see a medical profession these days referring to heterosexuality as normal. Suggesting a homosexual doctor could hide his or her sexuality "(by trying to "pass" as NORMAL)". This is such an offensive term; that gay people are somehow abnormal. What is normal? A 25 year old 72Kg caucasion male? I would have hoped someone writing an editorial on such a paper would at least try not to be homophobic (which that statement is). Dr M Lawton
Competing interests: None declared |
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Dan Saunders, Honorary Treasurer GLADD, BM Box 5606, London, WC1N 3XX
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I enjoyed reading Danny Riordan's important paper on the interaction strategies of lesbian, gay, and bisexual healthcare practitioners in the clinical examination of patients[1]. However I fear that the Editorial by Hughes[2] has perhaps partly missed some important points. All patients deserve to be cared for by competent healthcare professionals. Part of being a competent professional is the ability examine patients in an appropriate manner, regardless of the professional's sexual orientation, ethnic origin, gender, etc.. Hughes should not be 'guessing' that most patients would wish to know whether their doctor is lesbian or gay before performing a physical examination. It is not standard practice to explain to a patient, for example, that 'before I examine you I need you to know that I am happily married with three children'. I would challenge Hughes' opening statement that 'In the public mind doctoring and homosexuality do not sit easily together.'[2] Consent for physical examination is a complex area and the paper by Riordan has highlighted the need for further research, discussion and also education in this area. It is certainly possible to argue that all doctors should have a chaperone present for all physical examinations - this would be of benefit for the patient as well as the doctor concerned. However in an under-resourced NHS perhaps this is a little unlikely. I would also challenge Hughes' assertion that the greatest challenge to lesbian, gay and bisexual doctors is dealing with patients rather than colleagues. Despite the guidelines from the GMC and the recent legal changes, and regardless of what proportion of the lesbian, gay and bisexual medical profession they represent, GLADD members still frequently experience homophobia at work. More than 40% of respondents to a recent GLADD membership survey have identified that they have recently experienced workplace discrimination based on their sexual orientation. Despite the legal changes which now outlaw workplace discrimination on the basis sexual orientation, the Department of Health has yet to issue any constructive guidance on this important matter. Until we have reached a stage where the medical profession is able to deal effectively with true equality of opportunity for peers and colleagues, it is unlikely that we will be offering truly equitable treatment to our lesbian and gay patients. References [1] Riordan DC. Interaction strategies of lesbian, gay, and bisexual healthcare practitioners in the clinical examination of patients: qualitative study. BMJ 2004;328: 1227-9 [2] Hughes D Disclosure of sexual preferences and lesbian, gay and bisexual practitioners BMJ 2004 328 1211-2 Competing interests: I am the Honorary Treasurer of GLADD, the Gay and Lesbian Association of Doctors and Dentists. GLADD seeks to represent the views of its members to the medical profession on issues of importance to them |
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David Hughes, Professor in Health Policy Centre for Health Economics & Policy Studies, University of Wales, Swansea, Swansea SA2 8PP
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In courtesy to those who commented on my editorial, I wish to respond to some of the points made. The main message of my short piece was that gay, lesbian and bi-sexual (GLB) practitioners face ongoing problems in managing interactions, for which medical education offers little preparation. Although I am grateful to all those who took the trouble to express their views, I was puzzled to see that most choose to respond to things I did not say rather than to my core message. Dr Stammers is concerned about problems regarding ‘considerable numbers’ and ‘chaperones’. Actually, I stated in terms in the editorial that ‘we do not know’ how many GLB doctors there are, and mentioned the 10% figure and the lower NATSAL figure only as estimates that ‘some commentators’ have put forward. It is true that I said that the existence of active pressure groups in Britain and the USA suggests that ‘considerable numbers’ are involved. In that context I would consider a figure of several hundreds of practitioners in the UK to constitute a considerable number, large enough to justify changes in medical education to meet the needs of GLB practitioners. Dr Stammers’ mention of the 16 doctors interviewed by Riordan (a mis-statement of the actual figure of 13) serves only to make the issue seem smaller than it really is. On the question of chaperones I offered no recommendation about good practice, but observed that many GLB practitioners continue to use chaperones with patients of the opposite sex, ‘despite the feeling of irony that it engenders’. I highlighted the use of chaperones as one of Riordan’s most interesting findings because it exemplified the kind of interactional dilemmas that his respondents reported. I did not exclude bi-sexual practitioners because it seemed to me that compliance with a system that provided for surveillance of contacts with the opposite sex, but not their own sex, might indeed generate a sense of irony for some bi-sexuals. If pushed to offer a recommendation, I would say that practitioners who are concerned about litigation or misconduct allegations should consider using a chaperone for both sexes. Dr Saunders writes of my assertion that the greatest challenge for GLB practitioners is dealing with patients rather than colleagues. Riordan’s interviews focused mainly on dealings with patients, and I suggested that an implicit message of his article was that homophobia is more of a problem in respect of patients than colleagues. However, this is the context of my argument that qualitative interview studies may miss out facts that are unpalatable to respondents. I suggested that while the concentration on problems with patients in Riordan’s study was in line with earlier studies which seemed to show that professional colleagues were becoming less homophobic, it was also possible that Riordan’s respondents were reluctant to talk about occupational discrimination because this remained a painful issue for them. Unfortunately an extra ‘which’ inserted in my sentence by the copy editor may have partly changed the intended meaning here. Nevertheless, if Dr Saunders reads my editorial more carefully he will see that far from asserting that occupational discrimination is a thing of the past, I say that it is among the issues that need investigation in larger future studies. Other points made by respondents do reflect differences of view rather than mis-readings of my editorial. Dr Saunders’ position that professional practice entails certain competencies and standards which renders disclosure unnecessary is one that I respect, and I think it deserves to be aired in the future debate that will undoubtedly take place on this subject. Yet, patient wishes also need to be taken extremely seriously, and some of Riordan’s respondents clearly try to take this on board . It may be that public expectations are indeed changing, and that certain aspects of the professional’s life come to be accepted as simply not being relevant to the doctor/patient relationship, but in the post- Shipman, post-BRI health service I believe that the patient consent issue has to be included in the discussion. The challenge will be to find ways of accommodating patient preferences without allowing these to function as a mask for discrimination. Dr Lawton is concerned with my use of the word ‘normal’ and I accept that a different formulation would have been preferable. The difficulty was that I wished to use the editorial to introduce some terms in common use in this field, including the notion of ‘passing’ as coined by the famous Canadian sociologist, Erving Goffman. I imagine that the first question from most readers would be: ‘passing’ as what? And in Goffman’s book the unequivocal answer is ‘passing as normal’. By way of context one should say that within the micro-sociological tradition in which Goffman writes, ‘normal’ refers to conformity with the normative expectations (the role formats or frames) current within given social groups, and not to any ideal standard which could be contrasted with the abnormal. Nevertheless I concede that readers will consider this framework to be outdated and inappropriate (e.g. the book in which ‘passing’ features most prominently is entitled: ‘Stigma: Notes on the Management of Spoiled Identity’). I wanted to use the term ‘passing’ because it has been incorporated in the scholarly discourse on subjects such as sexuality and may still serve a useful purpose in getting across certain ideas, but perhaps the lesson is that we must now move beyond this older language. However, I hope that Dr Lawton will accept my assurance that I meant no disrespect to GLB practitioners. Competing interests: None declared |
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