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2.4.5 Respect for Difference � Sexual Orientation

Timothy F. Murphy, PhD

Updated December 1, 2013

Learning Objectives

  1. To identify obstacles to full disclosure by gay, lesbian, bisexual and transgender (GLBT) patients in health care relationships
  2. To identify the extent to which physicians can maintain confidentiality in relationships with GLBT adolescents
  3. To identify some strategies for securing better health care for GLBT patients

Case

Dr. Adrienne Deutsch is a pediatrician who has become "the expert" for adolescent medicine. At least, that's the way many colleagues in her community see her: they refer all kinds of adolescents her way, whether it's for severe acne, delayed puberty, emotional problems or obesity, among other conditions. Dr. Deutsch has a special rapport with adolescents because she had some unpleasant experiences with a doctor while an adolescent herself, and, during medical school, she swore she would never make the mistakes her doctor did.

In particular, at age 16, Adrienne once developed a vaginal infection, and her doctor asked her if she was sexually active. When she said that she was, the doctor immediately turned to a discussion of contraceptives and sent her away from the office with various samples and advice to use them in every sexual encounter. In fact, Adrienne had been having sex with another young woman, her first high school crush. She kept quiet during the doctor's talk about contraception rather than bringing up the exact nature of her sexual life. Her primary question — whether she should talk to her girlfriend about the infection — went unanswered. When that relationship broke up, Adrienne fell into a depression that she could not explain to anyone. Her doctor told her mother it was probably just a teenage phase.

In her practice now, Dr. Deutsch sometimes sees teenagers who are struggling with worries about homosexuality. She assures them that it's okay to have "whatever sexual orientation you have," just so long as your doctor knows about it in order to help protect your health. She also emphasizes confidentiality as she tries to speak in plain language. Dr. Deutsch is especially happy that more and more gay and lesbian adolescents not only are open with her but also are open about their sexual identity with family and schoolmates. In all these interactions, Dr. Deutsch does not disclose her own lesbian identity to patients unless they specifically ask about her own life.

Suzanna Gowings, aged 16 years, comes to see Dr. Deutsch because her asthma seems to be getting worse. In talking with Suzanna, Dr. Deutsch learns that Suzanna had previously been seeing Dr. Gabriel Chirac, a general practitioner in the same city. Suzanna says that she had a lot of difficulty relating to Dr. Chirac. She says that she did not feel comfortable talking to him and that he sometimes said hostile things about gay people and other minorities. This is not the first time that Dr. Deutsch has heard such things about Dr. Chirac. When Dr. Deutsch assures Suzanna that she will hear no such things in her office, Suzanna mentions to Dr. Deutsch that she has a girlfriend. Almost immediately, however, she becomes very quiet, as if that disclosure has been a mistake. She then asks Dr. Deutsch not to tell anyone else about this, especially her parents.

At this point, Dr. Deutsch wonders whether she could come out to this patient as a lesbian herself, in order to build more trust in their relationship. She has never yet had a parent ask directly about a child's sexual orientation, but she wonders what she would say if Suzanna's parents did ask. She also wonders whether she should contact Dr. Chirac and advise him that some of the things he has said are having a hurtful effect on his patients.

Questions

  1. Dr. Deutsch takes steps in her practice to make maturing adolescents feel comfortable about disclosing their sexuality. While this is important for all teenagers, in what way is it especially important — and perhaps problematic — for adolescents maturing into gay, lesbian, bisexual and transgender (GLBT) identities?
  2. In this case, a patient asks the physician to keep a sexual relationship confidential as well as any treatment she might receive. Are there any circumstances under which a physician should not keep this information confidential?
  3. Should Dr. Deutsch disclose her own sexual orientation to her patient as a way of establishing trust?
  4. What, if anything, should Dr. Deutsch do after hearing that a nearby doctor may be acting inappropriately toward GLBT patients?

Discussion

Q1. Dr. Deutsch takes steps in her practice to make maturing adolescents feel comfortable about disclosing their sexuality. While this is important for all teenagers, in what way is it especially important � and perhaps problematic � for adolescents maturing into gay, lesbian, bisexual and transgender (GLBT) identities?

Sexuality is a difficult topic to address openly for many people, and this difficulty can be compounded in adolescents as they mature. These difficulties are further magnified for adolescents who experience homosexual interests and behaviour, or conflicts of identity between their bodies and the gender identity they feel (transgenderism). Many GLBT adolescents are the only members of their family with that type of sexual identity, and they frequently lack visible role models and/or familial support to consolidate healthy sexual identities. In some instances, the adolescent's sexual orientation will not be known to the parents, making it all the more important for physicians to provide a safe space in which to discuss health and sexuality. Health care relationships work best when patients and physicians communicate openly and in an atmosphere of trust. For this reason, physicians may find it useful to set a tone of acceptance for all patients, in order to encourage the disclosure that works to mutual benefit in the relationship.

This view is supported by leading professional organizations that have adopted non-discrimination standards to protect GLBT patients coming forward for health care. For example, the Canadian Medical Association advises physicians as follows: "In providing medical service, do not discriminate against any patient on such grounds as age, gender, marital status, medical condition, national or ethnic origin, physical or mental disability, political affiliation, race, religion, sexual orientation, or socioeconomic status."1(article 17) The American Medical Association puts the matter this way: "... physicians who offer their services to the public may not decline to accept patients because of race, color, religion, national origin, sexual orientation, gender identity, or any other basis that would constitute invidious discrimination."2

Q2. In this case, a patient asks the physician to keep a sexual relationship confidential as well as any treatment she might receive. Are there any circumstances under which a physician should not keep this information confidential?

Ordinarily, parents are entitled to health care information about their minor children because they need that information to make testing and treatment decisions for children unable to make those decisions themselves. However, medical ethics and the law have carved out a domain of privacy for maturing adolescents.

Under some circumstances, maturing adolescents are entitled to privacy in their health care and can make decisions for themselves without parental notification or consent. The moral principle of respect for persons rests on the ability to make decisions, and maturing adolescents are growing into that capacity. For that reason, most jurisdictions permit maturing adolescents to make certain decisions about treatment for psychiatric conditions, sexual communicable diseases or contraceptives. In some jurisdictions, maturing adolescents may also elect abortions without parental notification or consent. Some commentators have argued that, under certain circumstances, some maturing adolescents who have grave illnesses should be entitled to forgo treatment that might extend their lives, even though doing so conflicts with their parents' wishes.

In any case, medical ethics and the law recognize the importance of respecting certain choices of maturing adolescents in a measure that is proportionate to the context of the choice. In the case here, a maturing adolescent does not wish her homosexual orientation disclosed to her parents. This choice assumes, of course, that the parents do not know, which may or may not be true. Assuming that the parents do not know that their daughter has sexual interest in other females, the physician could reasonably keep this disclosure in confidence since � by itself � the young woman's sexual orientation has no immediate implication for her health. In other words, that information is not germane to any current diagnostic or treatment decisions. If the parents did, for some reason, ask Dr. Deutsch directly about their daughter's sexual orientation, Dr. Deutsch could reasonably say that this is a question they could (and probably should) put to their daughter directly.

If that situation proves unlikely or undesirable, Dr. Deutsch might encourage the young woman to find a way to disclose her sexual orientation to her parents. Dr. Deutsch might even volunteer to be present when she does this, standing ready to answer questions that the parents and child might have and providing support for everyone involved. If, for any reason, Dr. Deutsch believed it was essential to the welfare of the adolescent (because of suicidal threats, for example) to disclose this information to her parents, she should advise the patient in advance of doing so.

Q3. Should Dr. Deutsch disclose her own sexual orientation to her patient as a way of establishing trust?

Many physicians unintentionally disclose their sexual orientation when they casually talk about their spouses in conversations with patients or display family pictures in their offices. The relevant ethical question here is whether a gay or lesbian physician enjoys that same privilege. In general, all physicians may be guided in these matters by thinking about the benefit to the patient.

In some instances, a physician's disclosure that he or she shares a common sexual orientation with the patient could work to reduce a patient's anxiety that his or her sexual life will be seen in a hostile or indifferent way. For example, some adolescents will take comfort in finding themselves in the care of a physician who knows the difficulties of coming out first-hand. Some physicians try to signal not their sexual orientation per se but their openness toward GLBT people by wearing GLBT-friendly symbols or placing those symbols in plain view in their offices.

On the other hand, other patients might be distressed to find themselves in the care of a homosexual physician, especially adolescent patients who have no prior social experience with homosexual men and women, let alone gay and lesbian physicians who will examine them and talk to them about their sexual behaviour.

For these reasons, a physician may disclose his or her sexual orientation when doing so works to establish trust in the health care relationship. However, there is no obligation to do so under all circumstances.

Q4. What, if anything, should Dr. Deutsch do after hearing that a nearby doctor may be acting inappropriately toward GLBT patients?

Dr. Deutsch has no direct knowledge that Dr. Chirac has said the things her patients have reported. She has no reason to disbelieve the patients, of course, but these statements may be inaccurate or distorted in important ways. For this reason, it would be unwise for Dr. Deutsch to complain directly to Dr. Chirac about his behaviour. Nevertheless, there is nothing that would prevent Dr. Deutsch from approaching Dr. Chirac and telling him, in a non-hostile way, that some patients have complained to her about things he has said.

Dr. Deutsch could also advise any patient who complained about hurtful statements made about GLBT people made in their presence that they are free to register complaints with the appropriate licensing agency. Licensing agencies work to ensure that physicians meet specific professional standards. Certainly, a physician who repeatedly demeaned any class of patients during the course of clinical care could be investigated and possibly sanctioned for professional lapses.

For her part, Dr. Deutsch might also work through various professional organizations to increase the knowledge about health care for GLBT patients. For example, she might participate in continuing education opportunities or share her observations through professional newsletters and journals. This kind of visibility in professional venues works against stereotypes and expectations that may keep some GLBT people from pursuing the healthcare they need and to help other clinicians meet high standards of professional care.

References

  1. Canadian Medical Association, CMA Code of Ethics (2012). Ottawa:  Canadian Medical Association; 2012.  Available from:  http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD04-06.pdf
  2. American Medical Association’s Council on Ethical and Judicial Affairs. Patient-physician relationship: respect for law and human rights. Opinion E-9.12. American Medical Association; 2007. Available from: http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/E-9.12.HTM&&s_t=&st_p=&nth=1&prev_pol=policyfiles/HnE/E-8.21.HTM&nxt_pol=policyfiles/HnE/E-9.01.HTM

Resources

  • Ginsburg KR., Winn RJ., Rudy BJ., Crawford J., Zhao H. et coll., �How to reach sexual minority youth in the health care setting: the teens offer guidance�, Journal of Adolescent Health, 2002, vol. 31, no 5, p. 407-416.
  • Lehrer JA., Pantell R., Tebb K. et Shafer MA. �Forgone health care among U.S. adolescents: associations between risk characteristics and confidentiality concern�, Journal of Adolescent Health, 2007, vol. 40, no 3, p. 218-226.
  • Beagan BL, Fredericks E, Goldberg L. Nurses� work with LGBTQ patients: �they�re just like everybody else, so what�s the difference?� Canadian Journal of Nursing Research 2012; 44(3): 44-63.
  • Society for Adolescent Health and Medicine. Recommendations for promoting the health and well-being of lesbian, gay, bisexual, and transgender adolescents: a position paper of the society for adolescent health and medicine. Journal of Adolescent Health 2013; 52:506-510.