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http://www.nytimes.com/2002/06/18/health/womenshealth/18CONV.html

Promising Judgments That Are Purely Medical

By CLAUDIA DREIFUS

ORTOLA VALLEY, Calif. — On a waiting room wall at Dr. Katherine A. O'Hanlan's office sits a small framed sign that reads: "This office appreciates the diversity of women and does not discriminate based on race, age, religion, ability, marital status, sexual orientation, gender or perceived gender."

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The sign is a prominent way of announcing a philosophy behind a medical practice. Kate O'Hanlan, 48, an oncological gynecologist affiliated with the Stanford University Medical Center, is a lesbian, a feminist and the past president of the Gay and Lesbian Medical Association. She has designed her office here, between San Francisco and San Jose, around a vision of what she believes patients want from a gynecologist.

She has a library of loose-leaf binders with information on topics like osteoporosis, breast cancer and cervical cancer. Each new patient receives a 24-page single-spaced brochure that the doctor prepared on prevention strategies and treatments for common maladies.

In the examination room, a machine with a camera lets patients see the organs the doctor is viewing.

"I want patients to feel I'm their healer, not their plumber," Dr. O'Hanlan said. "I treat them with respect, which means that I give them the information they need. People feel better when they sense they are being respected."
 

Q. During examinations, you ask your patients, "Are you sexual with men, women or both?" Why ask that question?
A. There are two reasons for it. The first is to signal my patients that I will respect them if they are lesbian, heterosexual or transgendered. The second is that I find it a good way to ask people about their behavior.

If a patient is lesbian, it's only going to alienate her if I ask, "Do you use birth control when you are being sexual?" That's an extremely loaded question because it presumes heterosexuality. To a lesbian, it can seem to her like the doctor is making a judgment, disrespecting her, rendering her invisible.

What I think is particularly useful about the way I've phrased my question is that it doesn't ask people to label themselves. Seventy to 90 percent of all lesbians have had sex with men, some within the last few years.
Q. Are the health problems of gay women all that different from those of heterosexual ones?
A. From some surveys done in the early 1990's, it seems that lesbians have a richer concentration of risk factors for gynecological cancers, as well as other cancers and heart disease. Gay women seem to eat more, drink more, smoke more. We need more research to see why.

Now, I should tell you that my practice — I treat cancers of the female reproductive system — is not disproportionately lesbian, though my gay patients are always glad to discover I am a lesbian.
Q. Is there a fear of doctors among many lesbians?
A. There seems to be a lot of anticipatory fear. If you've experienced homophobia, you expect the doctor to disdain you, not have time for you or might be trying to change you, and you will be less likely to go for help.

Many, many gay women say they don't go for health care because they've had negative experiences with discriminating doctors, or even with well-meaning ones who unintentionally marginalized them.
Q. When you say that gynecologists often marginalize their lesbian patients, what do you mean?
A. Let me give you an example. The very moment a woman walks into a gynecologist's office, she is handed a questionnaire. Under marital status, there are five different options to check, and all of them presume heterosexuality — married, widowed, divorced, separated or single.

That questionnaire, right there, marginalizes lesbians. A sixth check-off box for "domestic partnership" might recognize her situation.
Q. During your medical training, what were the attitudes that you observed toward homosexuals?
A. In the early years, the 1970's and early 80's, I mostly saw homophobia. I was in the closet then, and when you're in the closet, you hear all kinds of things. It's one good reason to get out of the closest, to stop people from saying bigoted things in front of you. Generally, they don't.

At medical school, the Medical College of Virginia, they would make fun of women who were not feminine. They mocked gay men for their perceived femininity.

I was a resident at the Georgia Baptist Medical Center in the early 1980's, when the AIDS epidemic first struck, and I heard people making fun of AIDS patients. I never said a thing. The year I was there, I was the only woman resident. I was admitted despite the fact they'd voted not to have any women and I was told that fact many times. All they needed to know was I was a lesbian!
Q. Did you always know you were gay?
A. My first knowledge of being a lesbian came when I was 5 years old and I liked the same girl that my brother did. Even then, I knew to hide it.

By the time I was 32, I was in Philadelphia, on a cancer fellowship at Thomas Jefferson Hospital and I began dating a younger woman. I was the first lady that she'd ever dated, and she kept trying to hold my hand when we were around the hospital. I gave her a lot of grief about that: "I'm negotiating a career here."

And she said back to me: `I'm not going to learn your shame. Whatever I do, I hold my head up high." She had to teach me that a career is not important unless you are valued as a person.

When we later moved to New York so that I could teach at Albert Einstein Medical College, I began slowly coming out by incorporating her in my conversations with colleagues. While at Einstein, I discovered that all of my colleagues' married spouses had health insurance and my can't-get-married spouse didn't.

So in 1988, with the help of my departmental chair, Dr. Irwin Merkatz, we got Albert Einstein to provide domestic partner benefits. It was a first, I believe, for American medical centers. A few years later, when we moved here to Stanford, we did something similar.
Q. You've pioneered new uses for laparoscopes, instruments where hysterectomies are entirely performed through tiny incisions in the navel. Why is this such a breakthrough?
A. Because women have shorter stays in the hospital, less pain, less disfigurement from the surgery. There's a quicker return to work, without sacrificing a thing.
Q. Don't you worry that the laparoscopic procedure will lead to more unnecessary hysterectomies?
A. I think the answer to that is an informed patient who knows how to say no when she's told she needs a hysterectomy for the smallest uterine fibroid. In my practice, the bottom line for hysterectomy is, Do the fibroids bother the patient?

Interestingly, because there is such widespread distrust of doctors when it comes to hysterectomy, I've seen a lot of women trying to preserve uteruses that really were a problem to them. When I'd suggest hysterectomy, the patient would say, "I don't want an unnecessary operation."

And then, I'd have to say: "Listen, you are having intense bleeding. You are anemic. You are missing a day and a half of work every month. This is affecting the quality of your life. Respect yourself."

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