CARING FOR LESBIAN AND GAY PEOPLE: A CLINICAL GUIDE Allan D. Peterkin, MD, and Cathy Risdon, MD What should you say if your patient is struggling with her sexuality? How do you respond to your married patient when he discloses to you his same-sex sexual history? To which medical studies do you turn when you need to know more about club drugs? As physicians and health professionals, you want to provide the best possible care for your patients, but medical schools and other health care teaching institutions do not generally provide comprehensive infor- mation on how to approach caring for sexual-minority patients++++arin+g Lesbian and Gay People++the first medical guide to offer busy clinicians practi- cal, accessible, and evidence-based information to help in the care of lesbian and gay patients. Allan D. Peterkin and Cathy Risdon begin with an overview of the history of medical relations with lesbian and gay patients, providing advice and guide- lines for strengthening the doctor-patient relationship and raising the standard of care for all patients. The book then delves into a range of specific clinical issues, such as risk profiles for particular illnesses, screening for and managing sexually transmitted infections, and HIV treatment in the primary care setting. Subsequent chapters cover a wide range of topics such as mental health care and the effect of homophobia on relationships, same-sex parenting, the role that body image plays in health, and unique populations, such as lesbian and gay ethnoracial minorities, the transgendered, rural lesbian and gay people, and elders. Each chapter includes practical tips (advice on inclusive language, for example) and summaries, along with references of written and online resources. Comprehensive and detailed, this work covers physical and mental health throughout the life cycle, with equal emphasis on women's and men's health. Based on more than twenty years of patient care and contributions to medi- cal education and community development, this indispensable resource will greatly heighten the quality of care that clinicians, health care practitioners, and educators can provide to their patients, and will in turn provide patients and consumers with the means to take an active role in their own health care. ALLAN D. PETERKIN, MD, is an assistant professor in the Department of Psychia try and the Department of Community and Family Medicine at the University of Toronto. CATHY RISDON, MD, is an associate professor and the David Braley and Nanc Gordon Chair in Family Medicine at McMaster University. This page intentionally left blank Caring for Lesbian and Gay People A Clinical Guide Allan Peterkin, MD, and Cathy Risdon, MD UNIVERSITY OF TORONTO PRESS Toronto Buffalo London www.utppublishing.com ©+U++n+iv+e+r+si+ty+ +o+f +T+o+ro+n+t+o+ P+re+s+s+ I+n+c+o+rp+o+r+at+e+d+ 2+0+0+3 Toronto Buffalo London Printed in Canada ISBN 0-8020-4857-9 (cloth) ISBN 0-8020-8379-X (paper) (oSo) Printed on acid-free paper National Library of Canada Cataloguing in Publication Peterkin, Allan D. Caring for lesbian and gay people : a clinical guide / Allan Peterkin, Cathy Risdon. Includes bibliographical references and index. ISBN 0-8020-4857-9 (bound) ISBN 0-8020-8379-X (pbk.) 1. Gays-Medical care. 2. Lesbians - Medical care. 3. Gays - Health and hygiene. 4. Lesbians - Health and hygiene. I. Risdon, Cathy. II. Title. RA564.9.H65P48 2003 362.1'086'64 C2002-905194-0 University of Toronto Press acknowledges the financial assistance to its publishing program of the Canada Council for the Arts and the Ontario Arts Council. University of Toronto Press acknowledges the financial support for its publishing activities of the Government of Canada through the Book Publishing Industry Development Program (BPIDP). For Robert. In memorium, Dr Ron Afanasiev and Dr Kelly McGinnis -A.P. For Lori, Gusto, Newton, and (in memorium) Alex. Also to Pat Kimura, Lynn Andrews, and Dave Davis for being there during the crucial turning points. My profound thanks for the depth of your generosity and inspiration to me. -C.R. This page intentionally left blank +++++++ Foreword++ix Introduction++xi Acknowledgment+++iii 1 Why a Clinical Guide on Lesbian and Gay Health? 3 2 Improving the Doctor-Patient / Provider-Client Relationship 13 3 Lesbians' Physical and Sexual Health 25 4 Gay Men's Physical and Sexual Health 44 5 Gay, Lesbian, and Bisexual Adolescent Physical and Mental Health 80 6 Diagnosing and Treating Sexually Transmitted Diseases 110 7 HIV Issues 124 8 The Mental Health of Gays, Lesbians, and Bisexuals 156 9 Substance Abuse 185 10 The Body 209 11 Relationships 236 12 Special Populations 260 13 Professional and Training Issues 291 14 Legal Issues 309 viii Contents Appendix A: Factors that May Indicate an Increase in Risk for Specific Diseases++323 Appendix B: Sample Legal Contracts++325 References+++335 Index++367 Online resources indexed at www.glbcare.com. Foreword The health of a nation, physically and emotionally, can only be as good as the health of its most vulnerable and stigmatized citizens. While culture, class, and religion are known to affect how illness may appear and be understood, sexual orientation has been less well researched or understood as a mediator of health and illness. Yet, as every gay, lesbian, or bisexual (GLB) person knows, developing a relationship with a medical or mental health provider that truly addresses the entire well-being of the person requires the provider not only to be tolerant but also knowledgeable about sexual orientation and its impact on psychological and physical health. Unfortunately, very little formal education or training in professional schools or clinical placements prepares clinicians with the knowledge and attitudes necessary to pro- vide competent and compassionate care to lesbian, gay, or bisexual people. Being open about one's sexuality to a medical provider is especially difficult if the patient perceives that sexuality in general, and same-sex orientation in particular, appears to make the provider uncomfortable. Even well-meaning providers can unwittingly create an atmosphere of discomfort for GLB people by assuming the patient is heterosexual and thereby forgoing the opportunity to ask the patient in a nonjudgmental way about his or her sexual orientation. Coming out as gay, lesbian, or bisexual over and over again in health care settings can be anxiety- provoking and difficult even for those people who have negotiated this process in other aspects of their lives. For young people particularly, health care providers can provide much-needed support for integrating sexual orientation into a positive self-image. Adolescence is an espe- cially difficult time for GLB people, and finding a health care environ-