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The Unintended Consequences Of Cultural Blindspots In Health Care

Doctors' unconscious biases about sexual orientation can adversely affect their treatment of LGBT patients. New national guidelines aim to fix that. (proimos/Flickr)closemore
Doctors' unconscious biases about sexual orientation can adversely affect their treatment of LGBT patients. New national guidelines aim to fix that. (proimos/Flickr)

Medical culture places a high value on the ideal of equal treatment. One would be hard-pressed to find a doctor who would admit to treating patients differently based on age, gender, race, ethnicity, sexual orientation, gender identity or any other characteristic.

Of course, life — and the exam room — are far more complicated than that. Research shows that health disparities exist for many patient populations, including inequities based on sexual orientation and gender identity. While rates of cervical cancer are the same among lesbians, bisexual and heterosexual women, for example, cervical cancer screening tests are performed far less frequently among lesbians and bisexual women.

...it is hard for doctors to believe that they may not provide the same quality of care to all of their patients.

Even when confronted with such facts, however, it is hard for doctors to believe that they may not provide the same quality of care to all of their patients. And in medical schools, the notion persists that if students are taught to relate to a generic patient in an open way, then they should be able to take good care of anyone.

But social scientists know better. In “Blindspot: Hidden Biases of Good People,” researchers Mahzarin Banaji and Anthony Greenwald show that bias exists on an unconscious level. Their popular Implicit Association Test measures the strength of a person’s automatic associations about a particular variable, such as sexual orientation. The end result of unconscious biases is that, even as health care providers, we tend to do more for those with whom we feel more comfortable. And we do not even realize when we’re doing it.

That said, some of the disparities in health experienced by lesbian, gay, bisexual and transgender (LGBT) people and others are rooted in genuine ignorance. Most transgender men, for example, should be screened for cervical cancer, as relatively few undergo hysterectomies as part of their transitioning process. Yet many doctors may not even think to ask their transgender male patients about whether or not they still have a cervix, and fewer still have the skills to conduct such an exam in a sensitive and gender affirming manner.

One way to combat inequities in treatment, whether they are rooted in ignorance or unconscious bias, is through education. Last month, the Association of American Medical Colleges (AAMC) published a guide for medical educators on how to train health care providers to care for patients who are LGBT, gender nonconforming, or born with differences of sex development (DSD). The guide includes a curricular framework for medical schools that can be easily adapted for use in nursing and other health professions training programs.

...students who are taught to continuously look for and reduce the harm that comes from unaddressed, unconscious biases of any kind will be able to provide more sensitive and culturally competent care to all of their future patients.

The suggested curriculum covers topics that range from simply increasing student awareness of the health risks and disparities faced by people in the populations described, to providing experiential learning through clinical scenarios (such as how to treat a transgender man with vaginal bleeding). The guide also lists 30 specific competencies a medical student should be able to demonstrate by the time of graduation in order to be entrusted with the care of people who are LGBT or born with differences of sex development.

Ultimately, the AAMC guide’s recommended approach to medical education has the potential to change the standard of care for patients who are LGBT or DSD. Moreover, students who are taught to continuously look for and reduce the harm that comes from unaddressed, unconscious biases of any kind will be able to provide more sensitive and culturally competent care to all of their future patients.

Related:

Jennifer Potter Cognoscenti contributor
Jennifer Potter, MD, directs women's health programs at Beth Israel Deaconess Medical Center and Fenway Health, and is a co-author of the AAMC publication.

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