LGBT Healthcare

How DADT Harmed Yours — and What You and Your Doctors Need to Know

By David Small, Associate Editor

Ten years ago, Today Show anchor, Katie Couric, had a colonoscopy on live television to promote preventive screenings after her husband died from colon cancer in 1998. It was uncomfortable to watch, but created a national conversation leading to an increase in the number of colonoscopies.

Today, gay service members would benefit from another live viewing of a different sort to help promote preventive health care among their community ­— an anal pap smear. It sounds uncomfortable, especially when it’s described as a bottlebrush inserted into the rectum. But it isn’t bad.

Most women receive a cervical pap smear to check for genital human papillomavirus (HPV). According to the Center for Disease Control, it is the most common sexually transmitted infection with more than 40 types, which the body can sometimes clear naturally. But on occasion, HPV will lead to cancer.

Like other sexually transmitted infections, HPV can also affect the mouth, throat or anus. Most people who have HPV do not know they have it. The CDC reports 10 percent of heterosexuals have HPV in the rectal region. Most recently, former Charlie’s Angel Farrah Fawcett died of anal cancer. “People using these areas as sexual organs should routinely get checked, even if they are not the receiving partners,” said Dr. Timothy Price, a civilian primary care physician at Price Medical in Washington, D.C.

While medical care for gays and lesbians is primarily the same as heterosexuals, there are some differences, such as the need to check for HPV more regularly. Just as doctors would treat a woman of childbearing age differently than one who is older, there are risks for certain things when treating LGBT members that ought to be factored into a clinician’s decision-making process.

But in today’s military, medical providers are not widely seeking the right information to assess an LGBT person’s health, and gay patients are not keen to volunteer the right kind of information to their military health care providers. These claims are according to an innovative, new study that assesses the public health impact of “Don’t Ask, Don’t Tell” (DADT), “How Military Health Care Just ‘Got Better’: Evaluating the Public Health Impact of DADT,” by OutServe member ENS Jonathan R. Barry.

DADT Caused Lost Health Care Opportunities

Ensign Barry, a third-year medical student on a Navy health professions scholarship at the University of Tennessee, seeks a military career in preventive medicine. More than a thousand LGBT service members responded to his survey. The questions assessed LGBT members’ knowledge, attitudes, health beliefs, behaviors and actions during and after DADT.

Respondents were equally spread among the services and were primarily active duty. Nearly 70 percent were enlisted, and 80 percent of respondents were male.

One of its most telling data points regards service members who wanted care for a particular LGBT issue through a military health care provider, but didn’t seek it because of DADT fears.

Nearly half of the respondents wanted help for a mental health issue related to their LGBT status. Furthermore, 30 percent desired help for a same-sex domestic issue, 26 percent wanted an STD test, 27 percent needed psychiatric care, and 31 percent sought other LGBT-related health care.

Unfortunately, none of these respondents sought help from a military provider. Small percentages of each did seek care external to the military medical community; however, most sought no help at all.

“The difference between the percentage of LGBT members who wanted health care and the percentage who actually received health care ranged between 15 and 30 percent, depending on the particular issue, and this can best be thought of as lost health care opportunities,” said ENS Barry. “DADT was largely viewed as a patient barrier, and this barrier was especially pronounced regarding mental health issues. Given today’s emphasis on mental health and well-being, I think it’s interesting there was so much undelivered care because of the sheer fear of DADT.”

The study also looked at patient behavior after DADT’s repeal, concluding that a residual effect from the defunct policy is still preventing patients from adequately disclosing information about their sexual practices.

“For most of the lifetime of DADT, there was a lot of ambiguity as to whether doctor-patient information was protected until it was explicitly outlined in a March 2010 DoD directive,” Ensign Barry said. “But even then, only one in five respondents knew about this highly significant policy change regarding DADT.”

It should be noted that there is no data comparing the rate at which heterosexuals sought similar health care. These numbers do not construe any conclusions about the rate at which gays and lesbians needed treatment for various issues compared to heterosexuals.

No Judgment

To combat these disconcerting claims, OutServe Magazine sought the advice of Dr. Price, an expert with 20 years of experience treating the gay community. He started Price Medical, a 2,500-patient, primarily gay medical practice in 1997 with the goal of being a comfortable place for gay people to seek medical care, knowing they won’t be judged.

“People need to be honest with their medical providers,” he said, noting his patients don’t have to explain how they end up in compromising situations. “From a medical provider’s point of view, the way you serve the population is by being open and non-judgmental about the person you’re seeing. That begins by accepting all types of people and behaviors as equal or valid options. We can’t have preconceived ideas about answers to questions.”

Ensign Barry agrees, “You don’t have to go to your doctor waving a rainbow flag. You don’t even have to necessarily tell your provider your sexual orientation. But it is important to clearly talk about who you have sex with — be them men, women or both — and how.”

To help foster disclosure, Dr. Price suggests providers give options and dig deeper to get a better picture of a patient’s sexual history.

“It’s a skill that has to be learned,” he said. “In medical training, people are not trained well to take sexual histories. Providers have to have practice, just like any other skill in medicine.”

According to the study, most gays and lesbians were unsure about whether doctor-patient privilege applied to disclosing their sexual orientation during DADT. Therefore the vast majority of military doctors have not had much experience culling sexual histories specifically from serving gays and lesbians. Without regular practice, as Dr. Price said, these doctors are wholly unprepared at this point to adequately treat this population.

One simple example Dr. Price gave is the standard form question, married or single? With respect to gays and lesbians, this question reveals nothing. A man could be married to a woman, but have had sex with men. Conversely, if a lesbian answers “single,” but is in a committed relationship with a woman, she probably doesn’t need birth control, said Dr. Price.

“[Not getting a correct sexual history] can lead people down the wrong path regarding health recommendations,” he said.

Just asking if a person is gay or straight won’t work because some men who self-identify as straight may still have sex with men, hence the clinical term, “men who have sex with men.”

However, some areas of the military only rely on a computer questionnaire to delve into a person’s history. Without a computer “red-flagging” a medical issue, a service member may not even have the opportunity to see a doctor for an annual checkup to discuss these points. This puts the complete onus on the individual to be forthright to computer-generated questions.

“The most you are required to do is show up for an appointment with an Airman who reviews your documents and asks if you have any questions,” said Air Force Capt Eddy Sweeney. “It’s ridiculous. This is something that absolutely needs to be addressed.”

Getting Tested

“Often I hear, ‘we’ve been together for 15 years,’ but that might not mean monogamously,” said Dr. Price. “The next question you have to ask is if a relationship is monogamous. And it isn’t so much the number of sex partners you have, but what you’re doing with them.”

While he said each person is different, if a person is engages in routine safer sex using condoms, he suggests STD and HIV testing every 6 – 12 months. Those engaged in riskier behavior should test at least every six months.

“If a person is monogamous, then most clinicians would say the patient is at low-to-no risk for STDs, and screening doesn’t need to be as extensive as those who are not monogamous,” said Dr. Price.

While the military regularly tests for HIV, typically, the calendar prompts the test and feeds a person’s deployment readiness vice routinely reacting to a person’s risk factors.

“Depending on the sophistication of the caregiver, service members might need to volunteer that they are fearful of having been exposed, otherwise non-specific symptoms may not get properly evaluated,” said Dr. Price.

A significant majority of patients having been infected with HIV will experience some kind of symptoms 4-6 weeks after exposure, he said. The symptoms present in a non-specific manner like the flu: fever, malaise, sweats, rash; and these could be mild to significant.

If a person engages in unprotected sex, then these symptoms could be a viral syndrome related to newly-acquired HIV. Doctors not routinely involved in identifying HIV patients may not recognize these symptoms, and patients not forthright disclosing their sexual history may be at risk for missing such a diagnosis, he said.

What Else?

Dr. Price recommended other preventive health measures for the LGBT community as well.

While not conclusive, some studies suggest that because of a hormonal change that occurs with birth control and pregnancy, lesbians not on birth control or prone to pregnancy tend to be at a higher rate of risk for breast cancer. Dr. Price suggests “screening and self-examination monthly needs to be more regular for lesbians.”

Lesbians, like anybody else, can also transmit other infections through skin-to-skin touching and fluid exchange.

For men who have sex with men, they should be properly vaccinated against Hepatitis A and B. “A records review of most military people shows that the military generally vaccinates against Hep A, but not Hep B,” said Dr. Price.

Regarding mental health, there can be a higher level of anxiety and depression disorders for LGBT people who are at the point of coming to terms with their sexuality, and who have repressed it within the military construct. “There is a stigma attached to people in the military if they admit any kind of emotional weakness,” he said.

Dr. Price recommends assessing a person’s mental health by using an open ended question such as “Tell me about your mood,” which puts the onus on the person to speak, versus going down a checklist of yes/no questions prompted by a computer screen, to which some military providers have resorted.

If military members have concerns about losing their security clearance, they should research the appropriate regulations. Going to mental health does not necessitate the suspension or revocation of a security clearance, and is generally situation-dependent.

The Military’s Response

As the era of DADT fades into history, it is expected that lost health care will diminish. However, the ability of providing specialized health care for LGBT people in the military is currently sparse.

After the Comprehensive Review Working Group issued its implementation plan for the repeal of DADT, no DoD medical policy changed.

According to a memo to the services from Clifford Stanley, the Undersecretary of Defense, “There will be no changes to existing medical policies. The Surgeons General of the military departments have determined that repeal of DADT does not affect the military readiness of the force and that changes to medical policies are not necessary.”

Spokeswoman for DoD, Cynthia Smith, said, “Medical personnel are educated and trained in dealing with the psychological and physiological aspects of gay and lesbian medical concerns, and that includes members of the military medical department.”

According to the Air Force Surgeon General, instruction on obtaining a comprehensive sexual history, and the professional and sensitive approach to doing so, exists within the core curriculum of national medical and nursing schools, to include the military medical school. However, among all the services, only the Navy and Marine Corps Public Health Center has any established resource for practitioners that specifically address the sexual health of LGBT troops.

“The Navy and Marine Corps Public Health Center maintains guidance for clinicians and healthcare providers on how to best address the medical concerns of the lesbian, gay, bisexual and transgender community,” said Navy Medicine spokesman CAPT Cappy Surette. The Navy’s information is publicly available on their sexual health and responsibilities resources webpage found at: http://www.nmcphc.med.navy.mil/Healthy_Living/Sexual_Health/msm.aspx.

The Army Surgeon General’s spokeswoman responded that the Army uses a broad-brush approach to comprehensive, holistic care for all aspects of any soldiers’ health, not specifically providing resources to treat LGBT members.

The Air Force Surgeon General believes that as their caregivers become more attuned to treating LGBT troops, that the specialized skills necessary to do so will increase. Having said that, there is no program, policy or effort to jump start increasing these skills for clinicians who likely haven’t had to deal with LGBT patients since school.

“Subsequent to medical training, the proficiency with which military providers and nurses elicit an LGBT person’s sexual history and deal with LGBT clinical issues is a function of both previous education and the nature and frequency of LGBT patient encounters. As openly practicing LGBT personnel in the military increase, our healthcare providers’ art in extracting historical detail, and LGBT patients’ comfort in revealing those details, will only improve,” said a spokesman for the Air Force Surgeon General.

These statements drive home the importance of LGBT patients being open and honest with their caregivers regarding their sexual history, putting the onus on the service member to be an active participant in their own health care.

“Patient privacy is a top priority for our providers,” said Captain Surette. “As such, self-disclosure by patients of any medical conditions or personal factors they feel could impact their medical care is imperative to ensure the provider is able to address their specific needs.”

Despite the services’ responses and lack of change to policy, there has been no department-wide effort made to enhance skills necessary to treat LGBT issues by military medical practitioners since repeal.

Recommendations

“By and large, most of the health care that gays and lesbians need is no different than the general population,” said Dr. Price. “Where it differs the most is when it comes to sex. What is it about this person’s sex life that either predisposes them or protects them from certain illnesses?”

Dr. Price encourages service members to realize that clinicians can’t read their minds; without disclosure, providers may base their judgment on possibly false assumptions. “They can’t make the proper recommendations if they don’t know the facts.”

Ensign Barry’s study concludes with specific directions to better foster an environment where doctors know the right questions to ask and patients are comfortable enough to answer those questions, thereby disclosing appropriate facts.

First, “efforts should be taken to not only collect data on the types and costs of lost health care, but also to educate LGBT members so that additional future health care can be delivered, helping to correct the discrepancies identified in this research,” he wrote.

With his data showing service members are not likely to disclose pertinent issues, Ensign Barry suggests additional resources be produced to inform and educate LGBT service members on how to be an active partner in their health care. “Resources could include what type of health information an LGBT service member should share with a military health care provider, why it should be shared, and how a provider will deliver personalized care based on that information,” states his study.

Lastly, Ensign Barry recommends further research in this area to examine, from both a patient and provider perspective, why such low percentages of providers ask medically relevant questions. This research should seek to enhance medical training and practice guidelines for military health care providers concerning LGBT health issues.

“In any patient pool, specific populations like LGBT members need not be disenfranchised from the system. This current data illustrates that there is a lot more work to do to get patients to be more open with their health care providers and health care providers to retool how they’ve been trained to better assist LGBT health issues,” Ensign Barry said.

“This is going to be a big change for the military,” said Dr. Price.

Ensign Barry’s research, “How Military Health Care Just ‘Got Better’: Evaluating the Public Health Impact of DADT,” was recently submitted to the journal of Alpha Omega Alpha, the national medical honor society, for an essay competition, and is not yet publicly available.