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.