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March 6, 2006
Dr. Harvey Makadon is an associate professor of medicine at Harvard Medical School and the director of education and professional training at the Fenway Institute, a group that helps educate clinicians about gay and lesbian health issues. He's written an article in the current issue of The New England Journal of Medicine on the need for doctors to better understand and care for the health of their gay and lesbian patients. Here are excerpts of a conversation he had Thursday with Globe correspondent Rachael Moeller Gorman:
Q: Why did you first become interested in health issues affecting gay men and lesbians?
A: At first, it was because I'm gay. It took me a long time to admit it to myself and then be comfortable enough to talk about it with other people. And it took a much longer time to feel comfortable actually living what I would consider now a normal life. As a clinician, I see many patients for whom those issues are still quite difficult, and I think it's very important for us to be aware of them and to help patients through them, and other very specific medical issues.
Q: What are these medical issues?
A: When people think of gay men they tend to think of HIV. I think it's important to recognize that there are a number of other issues which are important to consider in gay men -- prevention and screening for [other] sexually transmitted diseases is important. Knowing that gay men tend to have a higher rate of smoking and alcohol use is important. Knowing that there is a higher rate of eating disorders among gay men is important. . . . [In addition,] a lesbian might go in for health care and the doctor may assume she's not having sex with men and therefore doesn't need to have a pap smear [to screen for cervical cancer]. But what we know is that lesbians frequently have had sex with men and therefore should be treated with the same guidelines as any other woman. On the other hand, sometimes doctors feel that lesbians may be at higher risk for breast cancer, and that they should have mammograms either earlier or more frequently, but in point of fact that's never really been shown to be the case. . . .
Q: Do you think doctors don't deal with these issues because of a lack of education, because they feel uncomfortable, or a combination of the two?
A: Well I think, first, we're not taught much about it. Second, people aren't comfortable talking about sexuality in general. And I'd say, third, these are issues that take a long time to discuss. As you know, primary care providers are under greater pressure now to see patients quicker and quicker. We have to be prepared for time to actually talk to patients so they'll feel comfortable and that they weren't just rushed through something which might be the most important issue in their life.
Q: So, then, how should medical students be taught? And for doctors already in practice, should there be continuing education classes for them?
A: I would say at the very least there should be more education about human sexuality in medical school. Not just in medical school, but in nursing schools and schools of social work. So that people both feel comfortable with the issues and feel like they know what to do when patients bring up things that they're concerned about.
Q: Are sexually transmitted diseases among gay men and lesbians increasing?
A: Well, not among lesbians, but among gay men there has been a very significant increase in the last three or four years of syphilis, gonorrhea, as well as unusual sexually transmitted diseases which were rarely seen in the past. This is also fueled by a second epidemic, which is use of club drugs such as crystal meth or ecstasy which leads people to engage in increasing sexual activity.
Q: Do you think some doctors would consider it a type of profiling to approach someone about these issues based solely on their sexual orientation?
A: My sense is that it's important to get a sense of the epidemiology of what's happening in any community. If you're seeing a young gay patient, to ask them if they use club drugs isn't really profiling them. It's really just sort of being aware that this could be an issue. And if you look at the literature around the use of crystal methamphetamine and what a national issue this is, I think it's certainly reasonable to talk to our patients about it.
Q: How important do you think it is for a gay man or a lesbian to come out to his or her doctor?
A: There's one study that shows that lesbians who are out to their doctors feel they get better health care. And I do think that if you think about it, when you're honest with people about who you are, you tend to be more comfortable talking to them about your concerns. I think it only follows naturally that you would get better health care if you were feeling like you could be honest. I have a holistic view: I think it's important that we tend to not just medical issues but people's emotional issues. And if people aren't going to be open emotionally, we're never really going to be able to help them.
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