A guest post by Bianca Palmisano, founder and owner of Intimate Health Consulting.
“The gynecologist assumed that because I’d had male and female partners within the last year, I was irresponsible somehow. And to top it off, she didn’t even know what a dental dam was, when I told her I’d been using protection.”
“Even in trans-inclusive spaces, I’ve had a hard time accessing care that feels comfortable. Because I have not legally changed my name, doctors/practitioners consistently use my birth/legal name, especially when calling my name at the beginning of appointments and addressing me when asking questions.”
“When I went to the doctor in March and asked for more STI tests (I had been tested in January), they told me that it had been too recently since my last test. I blinked at them and sputtered, “But I’ve slept with a lot of people since then! I had to learn the code words that “a condom broke” or a “partner experienced symptoms” to get my insurance to cover more tests.”
These reactions by medical providers to sexual health requests from patients would be embarrassing if they weren’t so appallingly commonplace. The sad truth of the matter is that if you identify as some kind of sexual or gender minority—LGBT, non-binary, asexual, kinky, non-monogamous—you probably have a terrible doctor story of your own.
For most of us, it’s hard to understand the rationale behind these kinds of experiences: why can’t healthcare professionals just reserve judgment, treat everyone like a human being, and ask questions when they aren’t familiar with a certain community or practice?
The answer of course is inexcusably simple—because they don’t have to—but that apathy towards quality sexual healthcare is rooted in some complex medical, public health, and sociological issues.
Most medical professionals have been trained to address the malfunctioning of a specific body part: the broken bone, the fatty liver, the unexplained rash, the sexually transmitted infection. The disconnect between symptom and holistic patient experience is so marked in this profession that it’s spawned a whole offshoot of practice, osteopathic medicine, that shifts the medical gaze from symptomology to patient wellness. But most of us don’t see osteopathic physicians. We see MDs and their nurses, who have been rigorously engaged in this disconnected style of diagnosis for many years.
It’s pretty easy to see where I’m going here: when you see the symptom instead of the patient first, it’s a lot easier to discredit the importance of clinical empathy, compassionate non-judgment, cultural competency, and all those other important “soft skills” that make us more likely to actually LISTEN to our doctors. Doctors see a problem: you have an STI. They know the solution: a course of antibiotics and hearty dose of shaming so that you “never do something so reckless and irresponsible as to exposure yourself again.” The social and emotional implications of that shaming? Not really within a doctor’s scope of practice.
And where does that shaming come from? In part, medical shaming comes from the same toxic, sex-negative, intolerant society that we live in every day. Unfortunately, you can generally ignore or avoid the biphobic rants of your next door neighbor Randolph, but you’re wholly reliant on a doctor (and their attendant prejudices) to access your basic healthcare needs.
Even when doctors aren’t actively shaming their patients, they often simply lack up-to-date information and skills for talking about sexual health. The average MD receives barely 3-10 hours of instructional time covering sexual health topics over the course of a 4 year medical program. None of that is devoted to discussing bedside manner, unpacking prejudices, or confronting stereotypes. So if your doctor came into medical school thinking that queer people are promiscuous and deserve all the STIs they have coming, they’ll most likely leave medical school the same way. This lack of instructional time is compounded in shorter programs for nurses, medical assistants, phlebotomists, nursing home aids, and any number of other care professionals you might encounter.
Many educational programs are starting to incorporate content around LGBT health specifically, which is a good step, but even those efforts ignore so many communities and sexual health issues. Even public health, which has long claimed to be ahead of the larger medical community on minority health, has a limited lens through which to discuss sexual health. The public health model utilizes its own special cocktail of stigma to address groups that the CDC considers “high-risk”—primarily gay and bisexual cis-men, transgender women, Latino and Black cis-men, and Black cis-women. For these “high risk” groups, the prevailing understanding of the disease network is that individuals are sexually non-monogamous with many partners who rarely communicate their status. In the case of transwomen, the primary assumption is that most of their sexual partners are clients from sex work. While there’s some reality to those framing assumptions, the model doesn’t leave a lot of room for people who aren’t monogamously partnered or traditionally “high risk,” to say nothing of folks who fall into high risk categories but counter those expectations with low or no-risk activities.
And regardless of the healthcare domain or the amount of schooling, the vast majority of healthcare professionals will have had no exposure to BDSM, asexuality, polyamory, trans*-competent care, nor an understanding of how those identities and practices relate to risk reduction.
A truly great doctor (and a few of them do exist!) will have taken the initiative to self-educate on some of these issues, and will be proactive in their engagement around sexual health during an appointment. That means the first time you see a new provider, they should be taking your full sexual history, which is more than simply asking if you are sexually active. You should be hearing your doctor ask open ended questions like, “Tell me about any sexual concerns you would like to discuss,” and “How does the problem affect your life and relationship(s)?” or “What are your goals for your sexual health?”
Ideally you should know that your doctor runs an informed and inclusive practice as soon as you step into the waiting room, because the medical paperwork you fill out includes spaces to identity your sexual orientation and gender identity. A separate form might even offer a place for you to note other relevant social information, like whether you have an invisible disability or identify as a survivor of assault, stalking, or intimate partner violence.
But there aren’t a lot of stellar medical practices out there. And those that really do care and invest in a patient’s sexual health might not be good at signaling it to the outside world in their advertising or patient materials. Frequently, finding the right provider is a crapshoot where some get lucky and plenty more get disappointed.
Suffice to say, shit is hard. It’s going to take a huge investment of energy and a large culture shift from within and beyond the medical community to change these realities. My advice to those who are suffering the ignorance and prejudice of systems right now: if you have the means, vote with your voice, your dollars, and your feet. Promote the few really great doctors out there through social media networks, word of mouth, and review sites like RadRemedy, HealthGrades, and Vitals.com. Refuse to stand for ill treatment by those who are less informed and hold your healthcare provider to the highest possible standard. It is your health, after all, and you deserve informed, respectful, affirmative care. Full stop. No qualifications.
I’m in the middle of writing an academic paper on the effect of drug and alcohol use on contraceptive decision-making [edit: I actually originally wrote this post a couple of years ago, and the paper was eventually published here]. For many years, I’ve been a researcher in the public health world. But I’m a long way from being one of the people who actually has much influence over what doctors and public health professionals actually do.
When I started this research years ago, I’d never slept with anyone except my husband. I wasn’t exactly one of the people that public health professionals spend much time worrying about. And while I’ve still never had a drink or smoked a cigarette, I’m continually frustrated by the abysmal failure of the public health world to cope with the real lives of people like me, who live relatively “high-risk” sexual lives.
For starters, there’s the fact that my insurance doesn’t want to cover multiple STI (Sexually Transmitted Infection) tests a year. What the fuck??? When I went to the doctor in March and asked for more STI tests (I had been tested in January), they told me that it had been too recently since my last test. I blinked at them and sputtered, “But I’ve slept with a lot of people since then!”
It’s clearly in the best interest of the public as a whole (not to mention me and my partners) for me to get tested regularly. For Goddess’ sake, I can’t even calculate the extent of my overall potential disease network (I can calculate the very short fluid-bound intercourse network, but not the condoms-and-unprotected-oral-sex network). I would wager large sums of money that within three degrees of separation (my partners’ partners’ partners) that there are well over 100 concurrent people in it. It might very well be a helluva lot more than that. That’s an entire small community worth of people. Can’t my doctor just declare me to be a “high-risk case” and recommend me for more testing? Instead, I had to learn the code words that “a condom broke” or a “partner experienced symptoms” to get my insurance to cover more tests. Good grief. I’m 31-years-old and I don’t enjoy going to the doctor’s. I don’t get tested for kicks.
Then there’s the fact that the public health people really really really don’t get it. My doctor asked me if I had had “any new partners” since the last time I was in for an appointment. I realize that I haven’t explained my life in very great detail to her, but I’ve explained that I’m non-monogamously married, so she should know that me having a new partner only encompasses a relatively small portion of my overall STI risk. Back to that whole disease-network issue: what matters is what me and my partners and my partners’ partners are doing. The public health community really isn’t prepared to grasp the particular STI risks of people who maintain concurrent multiple partners.
And then there’s the way that the places that do offer cheap or nearly free testing tend to treat people when they go in. So far, I’ve been fortunate and never once been condescended to by a doctor when I went in for STI testing, but I’m guessing have a Ph.D. helps a lot with that. My husband complains that every time he goes in for testing, the doctors just look at him skeptically and seem to be assuming that he’s cheating on me (we got around this tidily one time by simply going in together, but that isn’t always practical). Other partners of mine have complained that doctors were extremely patronizing to them when they went in for testing. Medical condescension is not helpful. If you’re smart enough to be at the testing clinic, you’re smart enough to know that what you’re doing is risky. Doctors don’t need to lecture the people who are there getting responsibly tested. The people they need to lecture are the people who aren’t there. Lecturing people who’ve had the good sense to calculate their level of risk and realize that it’s not low just makes those people not want to come back and do the right thing. It’s like when teachers yell at the beginning of class about how “many students are late to this class”: it’s an understandable frustration directed at the wrong people. When people show up for preemptive testing (that is, symptom-free testing), say, “I’m so glad you’re here. Do you have any questions? Have some condoms! Please come back soon!”
It doesn’t apply to me personally, but I’m also frustrated by the total failure of the public health community to deal with the fact that the vast majority of “high-risk” sexual encounters (that is, casual sex with someone a person doesn’t know well) typically occur under the influence of drugs and alcohol. I haven’t figured out yet how to deal with that fact better, but I know that just assuming that telling people over and over again to use condoms will solve the problem is probably insufficient. In general, one of the great paradoxes of the public health world (that the medical community is totally blind to) is that the kinds of people who are most likely to have casual sex are the kinds of people who are most likely to be lousy contraceptors (hence my paper linked to above). Currently, The Condom Message has mostly penetrated the ears and brains of the people who are actually at very low risk (obviously, me and many of my friends would be an exception here…). I don’t know what to do about this problem other than to try to teach people to put condoms on bananas while intoxicated (or encourage them to put in female condoms while they’re still sober, but Goddess help a drunk person trying to use one of those things). What I do know is that a lot more smart people need to be putting their brains into solving this problem.
In conclusion, doctors and public health professionals need to start figuring out how to politely and successfully help people manage their changing sexual health risks in a world where traditional monogamy is becoming less popular overall, and where the average age of marriage just keeps going up and up (while the average age of virginity loss stays about the same). Current estimates say that 25% of young American adults will never marry, and our best-guess data suggest that various forms of consensual non-monogamy are becoming more popular. However, I can report that a growing body of research suggests that ethically non-monogamous people are, somewhat ironically, probably a lower STI risk to one other than “monogamous” people. Here’s the most recent study to say so. Go figure.