Date: Thu, 8 Aug 1996 02:56:26 -0300 (ADT) From: "Kevin R. Speight" Opening Doors: What Health Professionals Should Know About Their Gay, Lesbian, and Bisexual Patients by Kevin R. Speight, Dalhousie University Medical School Class of '97 (kevinsp8@is.dal.ca) Contents: Introduction What does 'homosexual' mean? What do "gay", "lesbian", and "bisexual" mean? Who are gays, lesbians, and bisexuals? Why is an understanding of sexual orientation issues relevant to providing health care? What is homophobia? What forms do homophobia and heterosexism take? How can you combat homophobia? When and how do you ask a patient about sexual orientation?2 How can disclosure of sexual orientation best be encouraged? Confidentiality Should physicians ever disclose their own sexual orientation to patients? What terms are appropriate to use? What is "gay bashing"? Spousal Abuse Suicide, depression and substance abuse When medical sources are in disagreement over gay and lesbian issues, which do you believe? When and to whom should I refer gay and lesbian patients? Do lesbians need reproductive health care? Are transsexuals and transvestites homosexuals? What safer-sex information should I make available to gay and lesbian patients? Emerging Issues Where can I go for more information? Conclusion References Introduction: While information on biological processes, diagnosis and therapy remain the core of medical education programs, many medical educators have recently recognized the importance of ethical, psychosocial, and sociological concerns to aspiring physicians. Here I address the question of homosexuality and medicine. I hope to provide a basic introduction on homosexuality and homosexuals to readers unfamiliar with the topic, to present a rationale for the importance of examining gay and lesbian issues in health care, and to give brief overviews of some selected topics relevant to the health care of gays and lesbians directed primarily at medical students. What does 'homosexual' mean? A homosexual is a person who exhibits "sexual desire or behaviour directed toward a person or persons of one's own sex."(1) The problem with using the word homosexual is that it assumes there are only two types of diametrically opposed sexual orientations, homo- and heterosexual, and that people are either one or the other. Sex researchers believe that people exist on a continuous spectrum of sexual preference. The Kinsey Scale rates people's sexual responsiveness on a scale of 0 to 6, with 0's exclusively heterosexual, 3's equal homosexual and heterosexual, and having sex exclusively with someone of the opposite sex, and 6's exclusively homosexual. Most people lie somewhere between the two extremes.(2) However, this classification can still lead to confusion, due to the necessity to consider both desire and sexual activity in classifying people's sexual orientations. It is entirely possible for someone who is mainly attracted to people of the same sex to have sex only with the opposite sex throughout his/her life. As well, sexual orientations may change throughout a person's life. A person who will later identify with a homosexual orientation may repress his/her attraction to same-sex people for years, and only become aware of his/her homosexuality after a period of exclusive heterosexual contact. People may go through periods of confusion when they honestly don't know what their sexual orientation is. Finally, people who have homosexual sex may not identify themselves as homosexual. Homosexuality can involve a cultural identity, but not necessarily. Some people who have homosexual sex label themselves as 'gay' or 'queer', socialize with other homosexuals, and may adopt elements of a gay subculture (e.g. characteristic phrases, manners of dress, literary and cinematic allusions). Others who have homosexual sex do not identify themselves as homosexual, may be married to an opposite-sex partner, and may even express anti- homosexual views. The point at which one labels a person as homosexual is unclear. It can be useful at times to use the term "homosexual" or "bisexual" to describe people who, as a minimum, are sexually attracted to members of the same sex. It is important to note the imprecision inherent in this term, and to realize the wide variety of sexual experience and feelings possible in people. What do "gay", "lesbian" and "bisexual" mean? Whereas homosexual is a term coined by doctors in the 19th century to describe a medical disorder, "gay" is a term that was first used as a secret code among members of a subculture, and later as a public self-designation by homosexual-rights groups.(3) It has a similar meaning as homosexual, but is preferred by many gay people, perhaps because it sounds less "clinical" and is a word chosen by gay people instead of being imposed upon them. Many homosexual women prefer to be called "lesbians". People who wish to be known as being sexually attracted to members of both sex often prefer to be called "bisexual". Some homosexuals proudly use terms like "fag", "dyke" and "queer" to describe themselves--such usage is not always appreciated by all homosexuals, probably because they were first used (and are still) as terms of derision by some people. I will use the terms "gay" to refer to people who have predominantly same-sex desires, and, when further distinction is necessary, "gay man", "lesbian" and "bisexual" in this text. Who are gays, lesbians and bisexuals? Homosexual behaviour is a trait which cuts across all cultures, races, occupations, nationalities, intelligence levels, and abilities.(4) Studies surveying the prevalence of homosexuality generally put the percentage of gay people at 5-10 percent of the population. (5) Kinsey et al's surveys of sexual behaviour found nearly 40% of the population of the U.S. is either homosexual, bisexual, or has experienced some same-sex sexual contact or feeling at some time in their lives.(3) These statistics remain estimates due to the reluctance many people feel in revealing homosexual activity or desire, but based on them, a physician who sees 30 patients in a day can reasonably expect 1-3 of them to be gay or lesbian. Gays and lesbians may engage in kissing, petting, mutual masturbation, and oral genital relations which are essentially similar and analogous to those activities as practiced by heterosexuals (6). Anal intercourse and stimulation are more common among gay men than among heterosexual couples, but a substantial number of homosexual men find this practice distasteful and engage in it rarely or not at all.(6) Anal intercourse should not be considered the sole domain of gay men-- some 30% of heterosexuals have tried it and some do it regularly(7). Most homosexuals do not show clear-cut active or passive preferences in this sexual relations.(6) Why is an understanding of sexual orientation issues relevant to providing health care? Unfamiliarity with issues surrounding gay and lesbian health care lead to a decreased quality of health care: "Misconceptions and unexamined personal attitudes about homosexuality on the part of physicians can result in grave, even life-threatening, disservice to homosexual patients.(8) There are several reasons for this: Sexual orientation may be a cause, contributor, or risk marker for health problems Gay people have different rates of health problems than heterosexuals. Gay men have higher rates of HIV infection than heterosexual men, lesbians, or women as of this writing.(9) Gay men may be at higher risk for certain sexually transmitted diseases or syndromes (syphilis, anal and pharyngeal gonorrhea, enteric infections, hepatitis, and certain intestinal complaints), and at decreased risk for others (chlamydia and trichomoniasis).(10) Sexually transmitted diseases are likely to have different presentations in gay men than in other people (oral and pharyngeal syphilis is more common in gay men than in other people, who are more likely to present with genital syphilis), and optimal treatment for sexually transmitted diseases may be different for gay men then for others.(10) Preferred diagnostic procedures may differ for people presenting with the same symptoms, depending on their sexual orientation (patients with rectal pain, diarrhea, colitis, or large bowel symptoms who are gay need not have an elaborate workup for ulcerative colitis until enteric infections, anal gonorrhea, and anorectal trauma have been ruled out.(10) Lesbians are at higher risk for breast cancer than heterosexual women.(11) Gays are also more likely to present with certain psychiatric problems, such as suicide attempts, and substance abuse.(12) While gay people may experience these problems due to the same factors as heterosexual people, negative attitudes towards homosexuality by themselves or by others can also contribute to them, and thus it may be impossible to treat the causes of a patient's psychiatric problems without knowing their sexual orientation. Gays, or people thought to be gay, may be physically assaulted for their sexual orientation (called "gay bashing"). Knowing the sexual orientation of such patients can aid law enforcement officials in preventing future incidents and in pursuing legal redress of such injuries. These observations change with differing temporal, geographical, social and environmental conditions, and thus may not always be valid, but they demonstrate the value of knowing a patient's sexual orientation in diagnosing and treating disease. A reluctance to discuss sexual orientation issues may preclude discussion of health issues If a gay patient doesn't feel comfortable revealing his or her sexual orientation, this makes it unlikely that medical problems related to sexual orientation will be dealt with. For example, if a gay patient with a sexual dysfunction isn't able to communicate his sexual orientation, many standard questions the practitioner should ask cannot be answered fully. Answering questions about a patient's relationship with his partner, under what circumstances has the patient ever had an orgasm, type of sexual fantasies the patient has, or sexual positions which change sexual response(13) often require the patient to reveal sexual orientation--if this is precluded, proper information cannot be obtained and the patient cannot be successfully treated. Other problems which fall into this category include spousal abuse, giving safer sex instructions, psychiatric problems related to sexual relationships or homosexual status, and enquiring about a patient's social supports when considering treatment options. Invisibility or negative attitudes worsen the doctor-patient relationship The therapeutic relationship between a physician and a patient is an important tool of medicine; along with other "placebo" effects, it may represent the difference between success and failure of therapy.(14) Therapeutic relationships share certain important factors, and a physician's attitudes toward homosexuality could influence these factors. The patient brings to therapy an expectation that help is possible(15). If, for example, a patient wishes a happier sexual relationship with his partner, and the physician feels no one can be happy in a homosexual relationship, then the expectation of help is destroyed. Therapy offers a safe place for taking risks(15). Negative attitudes about homosexuality make a patient less likely to take risks of disclosure and experimentation with new behaviours. When a patient realizes a physician is assuming he is heterosexual, or when a physician expresses negative attitudes toward homosexuality, some gay patients are less likely to trust and respect the physician. Without this trust and respect, an inferior therapeutic relationship may occur. A failure to disclose sexual orientation may be due to the physician assuming a patient is heterosexual (and the patient thus not having a chance to indicate otherwise), or to the patient's fear of disclosure. A physician need not be consciously aware of displaying overt disapproval for the patient to receive negative messages. Studies have shown that attitudes translate into behaviour. Experimental subjects tend to evaluate homosexuals more negatively than heterosexuals, all else being equal; they tend to maintain a greater personal distance from homosexuals, such as sitting further away and avoiding working with homosexuals.(5) Thus, negative attitudes, even in the absence of a desire to treat homosexuals differently, can be conveyed subtly to patients, thus impairing professional objectivity.(5) What is homophobia? This was a term coined by a psychiatrist, George Weinberg, in 1972 to mean the dread of being in close quarters with homosexuals. He argued that it commonly occurs in men who belittle homosexuals to bolster their own self-importance, and that in doing so, they heighten their fear of human variety and make it impossible to have homosexual friends, thus losing the possible benefit of a wider viewpoint.(16) Of late it is used to describe "any negative personal attitudes or behaviours about homosexuality"(17) One's attitude about homosexuality is not simply a matter or approval or disapproval. Negative attitudes can range from repulsion to pity to tolerance (homosexuals haven't "grown up" yet, and are to be treated with the protectiveness as indulgence of a child) to acceptance (implying that there is something negative to accept).(17) Positive attitudes can range from support to admiration to appreciation to nurturance(17). These positive levels of attitudes involve being aware of the climate homosexuals live in and the discrimination they face, assuming that lesbian and gay people are indispensable to society, and working to safeguard gay and lesbian rights. A term less frequently used when speaking about attitudes towards homosexuals is heterosexism; this may be defined as "the continual promotion by institutions of the superiority of heterosexuality and the simultaneous subordination of homosexuality...[and] the assumption that everyone is heterosexual unless known otherwise."(17) While others might debate what one's attitudes towards homosexuality should be, it is here sufficient to point out that negative attitudes towards homosexuals tend to worsen the health care they receive. What forms do homophobia and heterosexism take? The most blatant form homophobia takes is overt negative statements or actions. A gay patient may be devastated by hearing a respected figure tell him "All your problems stem from your homosexuality" or "That's the sort of problem you should expect is you are going to be gay", or "With my help, you can overcome your homosexuality". A refusal to acknowledge the importance of letting a homosexual's partner visit or participate in health-care decisions could cause distress. An inappropriate sneer or laugh can undermine the patient-doctor relationship. Homophobia may take the form of holding or expressing misinformation, myths, or stereotypes about homosexuals. Asking a gay man who has attempted suicide how long he has "wanted to be a woman" is an example of one stereotype about gay men--that they feel like women trapped in men's bodies. Expressing surprise upon learning that a person is gay because they look "so straight" expresses the stereotype that certain "types" are gay. This preconceived "type" for the gay man may look effeminate, strangely dressed and physically weak, and may have characteristics like being creative or artistic, being emotionally unstable and unhappy, having a dominating mother. The lesbian is sometimes thought to be mannish, physically active, unattractive, and anti-male. Other preconceived notions about gay people is that they are mostly promiscuous, that they are exclusively gay, and that they all engage in or are interested in certain sexual practices such as anal intercourse, sado-masochism, or pedophilia. These stereotypes are clearly not true of all gays: "there is as wide a personality variation among homosexuals as among heterosexuals...the seeking out of children as sexual objects is much less common among homosexuals than among heterosexuals".(6) Holding these stereotypes is as unfair as assuming certain races are less honest or intelligent, or that women do not have the temperament for medicine. Homosexuals are often "invisible" in our society--they are not talked about, and they are presumed to be "other people"--not one's friends, relatives, or patients. Some homosexuals, for fear of discrimination or dislike of their sexual orientation seek this invisibility. However, a lack of visibility in medical education can lead to inappropriate health care. Gay men do not only present with HIV-related problems--they can also have all the medical problems that heterosexual men do. Having hypothetical cases which never include gay men is not an accurate reflection of society. Similarly, not all pregnant women are heterosexual. Including examples of homosexual patients in medical problem-solving cases would reflect the reality of the patient population. A result of the invisibility of homosexuality is the assumption that a patient is heterosexual, unless specifically told otherwise. A negative response to the question "do you have a girlfriend" by an unmarried male should not result in the assumption that he is unattached. Indeed, a more open question might be "are you currently in a relationship", or a similar non-gender specific inquiry. It may be difficult to remember not to make assumptions about sexual orientation; however, by doing so, some gay patients will feel that their way of life is acknowledged by their doctor, and will feel more comfortable and confident in their doctor. Even if a doctor is not oblivious to the existence of homosexuality among her or his patients, discomfort talking about homosexuality and avoidance of discussing it can lead to the same result. A lack of knowledge about homosexuality and its relation to health provision can also lead to suboptimal medical care, even when a physician is aware of the possibility that a patient could be gay, and is comfortable discussing the topic. A negative attitude about homosexuality can lead to the presumption that a gay patient's health problem is caused by his homosexuality. A common example is psychiatric complaints. While it is true that a gay patient's depression may be related to the fact that he is gay, it may also be because he has stressors at work, at home or socially, or it may have an organic cause. Suicide, substance abuse or pneumonia in the homosexual may not be at all related to homosexuality, and a wise diagnostician seeks more information before reaching conclusions. How can you combat homophobia? Studies show that people who know at least one other gay person are less likely to feel discrimination against homosexuals is appropriate.(18) Thus educating oneself about homosexuals is a good place to start combatting homophobia on a personal level. Magazines, literature, journals and computer groups devoted to gay themes are excellent resources. If you already know gay people, talk to them about their experiences and lives. If you don't know any, you could attend a meeting of a gay group in your area. Being conscious of any assumptions you are making or any discomfort you feel surrounding homosexuality, and examining the reasons you have these feelings can be helpful. If you are yourself gay, coming out is a good way to reduce the invisibility of gay people and to help dispel negative stereotypes. If you find unusual difficulty dealing with gay issues or gay patients, you could seek counselling to investigate your feelings, or as a final resort, avoid treating gay patients: "When personal emotional attitudes interfere with an optimal physician-patient relationship and patient care, the ethical course is to explain one's dilemma openly and refer the patient."(6) On a community level, you can leave gay-positive posters and pamphlets around your office, and challenge homophobic comments, jokes, or attitudes made by colleagues or patients. On a population level, you can support laws and public education programs designed to combat discrimination against homosexuals. When and how do you ask a patient about sexual orientation? There are divergent views on issues like this. Some argue that a person's regular family physician should ask about sexual orientation: "These questions are neither academic nor prurient. Failure to know a patient's orientation dulls a physician's alertness to atypical manifestations or loci of some illnesses or lesions"(8). Others contend that such inquiries should only be made in the event the patient presents with symptoms which could be directly sex-related (e.g. STDs, sexual dysfunction). When considering this question, one must be sure that personal discomfort with the issue of homosexuality doesn't inappropriately limit patient questioning, and that ignorance of all the potential medical issues related to homosexuality hasn't improperly made the question seem irrelevant. How can disclosure of sexual orientation best be achieved? When dealing with sexual matters in general, begin with a sexual history only if the patient's chief complaint is of a sexual nature; otherwise, wait until you have established a rapport with the patient in the interview.(15) It can be helpful to indicate in your questions that many people have had homosexual feelings, in order to allay patient concern that their sexuality is abnormal: "Many people have sexual experiences with members of the same sex at some point in their lives. Have you had any experiences with other women (men)?"(15) When talking about relationships or sexual experiences, use neutral terms like "lover" or "partner" to avoid making it difficult for a patient to tell you about homosexual experiences. Both defense and denial about sexual orientation may occur by the patient under the best of circumstances, but they are greatly minimized by a matter-of-fact, nonjudgemental manner.(8) Discomfort or embarrassment in talking about sexual orientation will be communicated to your patient(15) and will hamper disclosure. If you doubt the answer a patient gives to a question about sexual orientation, and you feel it is medically important to know, it may help to explain to the patient why it is important for the physician to know, and that the information is confidential--direct confrontation may be counterproductive. Confidentiality: A patient's sexual orientation is part of his/her medical history, and should therefore be kept confidential where possible. The question of whether sexual orientation should be recorded on a patient's medical records is more difficult--on one hand, such an annotation can aid scientists conducting research on sexual orientation issues (the lack of such annotation was given as the reason why a recent study on "gay brains" excluded lesbians(19)). On the other hand, thought must be given to whether employers or insurance companies may see such an annotation and whether the patient will face adverse consequences because of this. One suggestion is to make annotations concerning sexual orientation with coded symbols particular to the physician. Should physicians ever disclose their own sexual orientation to patients? One author claims that heterosexual therapists, even those who wear wedding bands, usually quote therapeutic neutrality, claiming that sexual orientation should never be disclosed. In contrast, the response from gay identified clinicians seems to be overwhelmingly in favor of personal disclosure of their sexual orientation to gay patients, but not necessarily of any further specific information. More importantly, many gay therapists believe that the disclosure is an essential and therapeutic part of the process, and example of role modelling.(20) Another is more emphatic: "minority therapists...must come out and reveal themselves because they must model being genuine".(20) A gay man may find a heterosexual male physician intimidating, and prefer to deal with a female.(20) However, a heterosexual therapist who reveals his or her sexual preference may allow for an honest projection of fears, assumptions, and negative transference.(20) These issues are more important in psychotherapy, but the impact of physician disclosure should be considered in all medical settings. What terms are appropriate to use? When in doubt, use the most neutral and widely accepted terms for sexual orientation and sexual activity, but use the patient's own vernacular when it is known.(15) What is "gay bashing"? As an adjunct to other forms of discrimination gays and lesbians face, they may be physically assaulted based on their actual or presumed sexual orientation. Statistics on such "hate crimes" are only beginning to be kept, and do not fully reflect the extent of the problem, because many gays and lesbians do not report the crimes. Patients who have been assaulted may also not disclose the nature of the assault to the physician. Patients may require counselling after such an attack, and may also obtain emotional benefit from legal remedies. For these reasons, physicians should be alert to the possibility of gay-bashing in assault cases, make disclosure comfortable by the patient, and refer him/her to appropriate resources. Prevention can be encouraged by advising patients to take personal security measures such as self-defense courses, not travelling alone, and avoiding confrontations. Spousal Abuse: Victims of spousal abuse are commonly thought to be women abused by male partners. Physicians should be aware that abuse (physical, emotional, and sexual) can also occur in lesbian and gay relationships. One gay man told of how the ignorance of health care providers adversely affected his situation: "[My abuser] once agreed to counselling. The psychiatrist having no background in gay male abuse doesn't see the problem. The abuser refuses to ever go again....I tried to commit suicide twice....No one asked why I tried to kill myself."(21) Suicide, Depression, and Substance Abuse Studies have shown that gay men and lesbians are a significantly higher risk for suicide and alcoholism(12). Discrimination faced by lesbians and gays is a major factor explaining these statistics- -nothing inherent in homosexual activity makes a person self- destructive.(12) Lesbian and gay youth seem to be at particular risk--one study should gay youth are two to three times more likely to attempt suicide than heterosexual youth, and up to 30% of those teenagers who do commit suicide are gay or lesbian(22) However, this relationship is not always recognized by physicians. Thus in patients presenting with depression, suicide, or substance abuse issues, it is important to determine the role sexual orientation may be playing. It is also important to note that gays and lesbians may also experience these problems for reasons unconnected to their sexual orientation--a lesbian patient may be depressed because of poverty, or may drink because of an inability to cope with a stressful job, for example. When medical sources are in disagreement over gay and lesbian issues, which do you believe? The general medical view of homosexuality has changed over the years--from advocating castration of male homosexuals, less than 60 years ago(3), to asserting that homosexuality is not a disorder today. For that reason, the currentness of a medical book or article is relevant when using it for medical information on homosexuality. Some aspects of psychiatry are necessarily based on theories (e.g. Freud's psychosexual theory of development) and are not amenable to rigorous scientific testing. For this reason, the assumptions and biases of a writer using this technique to produce information on gays and lesbians must be questioned. The author's sexual orientation and cultural surroundings could be important to how she perceives normal and abnormal human behaviour. Studies which attempt to study homosexuals in a scientific manner face an important problem which can affect their validity: it is difficult to obtain a truly representative sample of homosexuals, due to the limitations in definitions of homosexuality and the reluctance of some gays and lesbians to self-identify as homosexual to a researcher. If a study is done outside an establishment where gay men are known to congregate for sexual encounters (i.e. a bathhouse), for example, data on the average number of sexual partners for gay men are only representative of those men who frequent such establishments, not of gay men in general. Data on the mental state of lesbians obtained from lesbians being treated in a psychiatric hospital are not representative of all lesbians. Thus it is necessary to critically evaluate medical literature on gays and lesbians for such factors as the date of the study, the biases of the author, and the representativeness of the sample. When and to whom should I refer gay and lesbian patients? The normal customs regarding referrals apply to gays and lesbians (i.e. when you lack the time or expertise to deal with a patient, refer to a professional who can better manage the problem). It may be valuable to avoid referring a gay or lesbian patient to a professional who you know to have strong negative views of homosexuals, when possible, in order to provide for the best possible doctor-patient relationship. Especially with a patient who has medical issues relating to their sexual orientation, you may wish to consider referring to a self- identified gay professional: "Given the paucity of training on issues of a gay affirmative psychotherapeutic approach, the burden is on the non-gay therapist to be competent...most gay therapists who intentionally work with gay couples have a decided advantage"(20) Do lesbians need reproductive health care? Since lesbians do not generally have male partners, many people aren't aware that some choose to have children, and many other people disapprove of such action. Nineteen out of 33 fertility clinics surveyed recently in Canada said they would refuse treatment to lesbians(23) When making a decision to refuse treatment, the following issues could be rewardingly considered: Is there a good medical reason to deny such service? Does such denial have anything to do with my assumptions that homosexuals are child molesters, or that sexual orientation in a child is determined by the sexual orientation of the parents, or that homosexuals are incapable of making good parents? If so, have I investigated these assumptions thoroughly? Is such a refusal consistent with the letter and spirit of the Canadian Medical Association Code of Ethics, the Canadian Charter of Rights and Freedoms, and any human rights legislation in my province? Are transsexuals and transvestites homosexual? The majority of transvestites (those who wear clothes of the other gender) and transsexuals (those who feel a dissonance between their gender assigned at birth and the gender role they wish to assume) are heterosexual.(15) Their situation has in common with homosexuality the fact that they are challenges to traditional gender roles, and that many transgendered people are homosexual. As well, activists who label themselves "queer" have undertaken to include transgendered rights issues with those of homosexual rights. As with definitions of homosexuality, there are problems with definitions of these transgendered people. While transvestism is for some a paraphilia, others dress as the opposite sex for broader social reasons. Transvestism and transsexualism may overlap. The current medical definition of transgendered people as deviants and disordered(15) people could be amenable to similar criticisms used against the medical definition of homosexuality as disease, which existed until recently. For example, when treating transgendered people who are depressed or suicidal, it may be useful to examine whether these feelings are an inherent part of the "disorder" of transvestism or transsexualism, or whether they are merely a result of the discrimination and disapproval faced by these patients. Efforts to change these traits must be balanced with the testimony of transgendered people who report greater happiness and satisfaction after they embraced their desired gender roles(24). What safer-sex information should I make available to gay/lesbian patients? Safer-sex pamphlets are commonplace in physicians' offices now, but few seem to be directed specifically to gay patients. You may wish to consider obtaining pamphlets which are gay-specific, gay positive, and even erotic. Safer-sex information put out by gay organizations tends to be more specific, more appealing to its audience, and, as one study showed, more effective than other safer-sex information.(25) Gay men are more likely to be receptive to safer-sex information which communicates to them in a way that is erotic and non-judgemental.(26) Emerging Issues: The rapid rise of genetic technologies may give rise to new ethical issues in the future. For example, if a genetic cause for sexual orientation were identified, would it be acceptable for women to use this test to abort fetuses based solely on the probable sexual orientation of the unborn child? If a way were found to change sexual orientations, or to influence the future sexual orientation of a child, should these technologies be used? These issues may test the tolerance, compassion, and ethical standards of the medical profession. Where can I go for more information? Via computer on the Internet, considerable information can be gleaned from newsgroups such as soc.motss, soc.bi, sci.med.aids, alt.politics.homosexual, alt.sex.motss, alt.sex.homosexual, alt.transgendered, and others. The electronic mailing list glb- medical is currently run and moderated by the author, and can be reached at kevinsp8@ac.dal.ca. Local gay and lesbian organizations can provide information and referrals. For example, GALA NS (Gay and Lesbian Association of Nova Scotia) 2112 Gottingen St., Halifax, B3K 3B3, 423-2292. Gay Alcoholics Anonymous 461-1119 Lesbian, Gay and Bisexual Youth Groups, Planned Parenthood N.S., 6156 Quinpool Rd., Halifax, 492-0444 (Maura) BGLAD (Bisexual, Gay and Lesbian Association at Dalhousie) 494- 1415, third floor of the Dalhousie Student Union Building. PFLAG (Parents, Families & Friends of Lesbians and Gays) Ron at 443-3747. Safe Harbour Metropolitan Community Church 443-7751 AIDS-Nova Scotia 425-4882. Inform-AIDS toll-free hotline: 425-2437 Gay/Lesbian/Bisexual Line 423-7129 Nova Scotia Persons With AIDS Coalition 429-7922 Many other gay organizations exist in Nova Scotia and in other provinces. The Gaezette can be consulted for more information (Box 34090, Scotia Square, Halifax, B3J 3S1). It is available free at several places in Halifax and elsewhere, and is a resource you could consider placing in your office. Some counsellors advertise to the gay community, for example, Dr. Blye Frank, 425-4534, Jenna Smith, 422-0087, ext. 61, and Darlene M. Young, 461-9443. Other professionals knowledgable with gay and lesbian health care can be found by asking colleagues or consulting local gay organizations. The Gay and Lesbian Medical Association is composed mainly of gay and lesbian physicians and is concerned with gay and lesbian health care issues. They can be reached at 211 Church St. Suite C., San Francisco, CA 94114, ph 415-255-4547, e-mail gaylesmed@aol.com. They are currently expanding into Canada. The American medical student's group has a gay/lesbian caucus which are also active in these issues. Conclusion: It is important to emphasize that this essay is only a brief overview of some of the issues important in providing health care to gays and lesbians. Further investigation of these topics is encouraged, and have hopefully been facilitated by their inclusion here. Attitudes and information on gays and lesbians are constantly changing, and thus physicians must keep up-to-date on these issues. It is important that heterosexual physicians join many gay and lesbians physicians in an increased awareness and understanding of these issues and work for positive change. A substantial increase in the quality of health care is possible as a result of such awareness and understanding. References: 1. Random House Unabridged Dictionary. 2nd ed. New York: Random House, 1993. 2. Kinsey AC, Pomeroy WE, Martin CE. Sexual behaviour in the human male. Philadelphia: W.B. Saunders, 1948. 3. Katz JN. Gay/lesbian almanac: a new documentary. New York: Harper & Row, 1983:16,15,536. 4. Muchmore W, Hanson, W. Coming out right. Boston: Alyson Publications, 1991:12. 5. Schneider MS. Often invisible. Toronto: Central Toronto Youth Services, 1988:19,45. 6. Marmor, J, ed. Homosexual behavior: a modern reappraisal. New York: Basic Books, 1981:268,267,81. 7. Zilbergeld B. The new male sexuality. New York: Bantam Books, 1992:123. 8. Lief HI, ed. Sexual problems in medical practice. Chicago: American Medical Association, 1981:79,86,80. 9. Mulligan R. The changing profile of the HIV/AIDS epidemic. J. Calif. Dent. Assoc. 1993 Sep;21(9):23-8. 10. McCormack WM. Sexually transmitted disease: special problems of homosexuals [videorecording]. New York: Network for Continuing Medical Education, 1980. 11. The Advocate, 1993 Feb 9. 12.Rofes EE. I thought people like that killed themselves. San Francisco: Grey Fox Press, 1983:23,73,1. 13.Guillick EL, Peed SF. Role of the health practitioner in family relationships: sexual and marital issues. Westport, CT: Technomic Pub. Co., 1978:75 14.Goodman A, et al, eds. The pharmacological basis of therapeutics. 8th ed. New York: Peramon Press, 1990:72. 15.Waldinger RJ. Psychiatry for medical students. Washington: American Psychiatric Press, Inc., 1984: 310,220,221,239. 16. Weinberg GH. Society and healthy homosexual. New York: St. Martin's Press, 1972:1-3. 17.Homophobia, heterosexism and AIDS: creating a more effective response to AIDS. Ottawa: Canadian AIDS Society, 1991:6,53-54. 18.Ellis AL, Vasseur Rb. Prior interpersonal contract with and attitudes towards gays and lesbians in an interviewing context. J.Homosexuality. 1993;25(4):31-45. 19.LeVay S., quoted in The Advocate, 1994 Jan 25:87-88. 20.Stein TS, Cohen CJ, eds. Contemporary perspectives on psychotherapy with lesbians and gay men. New York: Plenum Medical Book Co., 1986:132,99. 21.Johnson R. Abuse in gay and lesbian relationships, presentation at Atlantic Gay and Lesbian Conference, October 1993. 22.Maguan S. Teen suicide: the government's cover-up and America's lost children. The Advocate 1991:586. 23.Campbell S. Learning to play with turkey basters and syringes. X-TRA! 1994 Feb 18:17. 24.personal communications from self-identified transsexuals and transvestites reading the internet newsgroup alt.transgendered, for example. 25.de-Vroome EM, Pallman ME, Sandfort TG, Sleutjes M, de-Vries KJ, Tielman RA. AIDS in the Netherlands: the effects of several years of campaigning. Int. J. STD AIDS 1990;1(4):268-75. 26.Adelman MB. Sustaining passion: eroticism and safe-sex talk. Arch. Sex. Behav. 1992;21(5):481-94.