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1 Gay-friendly Doctor Handbook

2 Table of Contents Why the Dr. Rainbow Scheme? 01 Why the Dr. Rainbow Scheme? 05 How do I become a Dr. Rainbow? As a professional doctor, I am treating all patients equally regardless of their sexual orientation and identity, why should I join the scheme? 08 Particular Health Concerns of Gay Male Patients What doctors say about their patients experiences. 10 Particular Health Concerns of Lesbian Patients 12 Dispelling Myths A male patient once came to my clinic for medical consultation with a sore throat, who had taken antibiotics under another doctor's prescription but was getting no better. After having a detailed inquiry with him, I found that he had had oral sex with men before. Having a sore throat was actually the symptom of being infected with gonorrhea, but not catching a cold or a flu. Therefore, even if the symptoms may be ordinary, a careful and attentive inquiry is still required to help the patient solve his/her physical distress. 13 Gay Slang Dr. Fong Yeung Family Medicine Specialist The scheme is sponsored by the Equal Opportunities (Sexual Orientation) Funding Scheme. Any contents of this material / any activities organised under this project do not represent the position of the Government of the Hong Kong Special Administrative Region 1

3 Patients who come to my clinic are usually having mental distress. As a psychiatrist, I must understand all aspects of the patient's life including their family and relationships. Every life stage can be a challenge for LGBT persons the struggle of coming out to the family when they are young, the anxiety of hiding their sexual identity when they are dating, the stress of living another life of a heterosexual as a disguise. Even when they are old, they still have to suffer from the pain of not being able to arrange the after-death matters of their deceased partner due to the lack of marriage recognition in Hong Kong. Therefore, if the patient's sexual orientation is not well-understood, it is difficult to figure out the trouble they face accurately and holistically. Patients will tell you what is truly troubling them in their lives only when you are believed to be open-minded and non-judgmental. Dr. Fung Wai Choy Psychiatrist Gay patients need to be treated equally and they need your sensitivity too! As long as the information related to the patient s sexuality is clinically relevant, I would ask the patient about their sexual orientation carefully. It has basically become part of my consultation practice. For example, if a patient has shown some skin rashes, or any signs of sexually-transmitted infections on his body, I would ask the patient about his/her sexual orientation and sexual practices. If he is a 10 (versatile), and has engaged in anal sex with another man before, I would take a swab from both his urethra and anus for a comprehensive physical examination. In fact, as long as the patients understand the relevance between my inquiry into his sexuality and his health condition, they don t really mind disclosing their sexual orientation. If a doctor can ask the patient about his/her sexual orientation and related issues sincerely, a more accurate diagnosis can be made. Dr. Rainbow Scheme is also developed to prevent patient experiences like these Case 1 When I walked into the Social Hygiene Clinic and told the doctor that I would like to have check-ups, he asked me if I was gay and I admitted that I had sexual contact with men before. He looked shocked and asked me some questions as if I was in interrogation, like you play games like that? and did you do that thing? I regret disclosing my sexual orientation. I hope that doctors could understand that sexual orientation is not something you play with, but is something you are born with. Dr. Wong Chun Fung General Practitoner 2 3

4 Case 2 I went to a general practitioner for the treatment of diarrhea and disclosed my sexual orientation in the consultation. The doctor looked really shocked and started to talk about the Bible, saying that God doesn t permit homosexual acts. He did not do any check-ups for me and gave me some antibiotics right away. I felt really disrespected. I hope that doctors would not let their own opinion on homosexuality affect their clinical assessment or propagate their religious values in consultation. Case 3 I went to a general practitioner for STI check-up. The doctor was very shocked when I disclosed my sexual orientation and recommended that I go to the New Creation for counselling and conversion of my sexual orientation. I felt really offended. My sexual identity is not a mental health illness but he treated me like I have some kind of problem. 55% of the gay men would hide their sexual orientation when they seek sexual-health related medical services. 20% of the gay men would not seek medical services for fear of disclosing their sexual identity. According to the International Code of Medical Ethics, a physician:- shall NOT permit considerations of sexual orientation to intervene between [his/her] duty and [his/her] patient. shall NOT allow his/her judgment to be influenced by unfair discrimination. The above code is adopted by the World Medical Association and the Medical Council of Hong Kong will have regard to the International Code in the exercise of its disciplinary power to registered medical practitioners in Hong Kong. AIDS Concern believes that the majority of Hong Kong medical practitioners put the health of their patients as first priority and do not want their gay patients to worry about having the above patient experiences. If you join the Dr. Rainbow Scheme, we will provide you with information and resources including a workshop on the culture and health concerns of the gay community, to assist you in providing optimal care to gay patients. How do I become a Dr. Rainbow? Source: AIDS concern s online survey conducted in January

5 Familiarize with the healthcare needs and 1 culture of the gay patients The relationships and sexual practices of gay people might be different from those of heterosexuals, as most of them do not perform penetrative sex that may cause pregnancy. You may have to apply a different lens in consultation with gay patients if your specialty involves clinical assessment related to sexual health, and discuss sexual health issues with all your patients openly in a non-judgmental manner. For more information regarding the particular healthcare needs of gay patients, please refer to P.8. Make gay patients feel welcomed in the 2 access and intake process Display leaflets of gay community health concerns or post the rainbow sticker in the clinic. Maintain a culturally safe environment for 5 gay patients Provide training to all staff in the service to ensure they are confident and understand their responsibilities about delivering gay-friendly practice. Respond to breaches of gay-friendly practice by staff and make sure the related staff know the importance of gay-friendly practices in the clinic. These may be small changes for you, but they can mean big differences for your gay patients! Increase your sensitivity to diverse sexual 3 identities in consultation A lot of gay patients may feel embarrassed if healthcare professionals assume that their partners are of the opposite sex. You may use gender-neutral language such as partners or significant others when talking about sexual relationship of the patients. Ask open-ended questions and avoid making assumptions about the sexual orientation or behavior of the patients. Make gay patients feel safe to disclose their 4 sexual orientation Ensure the privacy of your patients. When the patient is accompanied by his family members, you may ask the patient if he needs to be alone for consultation to avoid his unwanted disclosure in front of his family members. Inform patients that the information about sexual orientation is confidential. If you also agree that gay patients need to be treated sensitively, please do not hesitate to contact us and follow the steps below, so that we can provide you with further resources on gay-friendly healthcare practices Fill in the application form Get a rainbow sticker from us and you may choose to post it in your clinic to build a gay-friendly medical environment Join our gay-friendly healthcare training workshop or webinar Receive regular updates from us about the latest trends and healthcare concerns of the sexual minorities 6 7

6 Particular Health Concerns of Gay Male Patients 1 HIV and sexually transmitted diseases (STDs) Sexually active gay men are at an increased risk of HIV and STD infections. 5.85% 6% HIV prevalence among the STD prevalence among gay community in gay men in Anal intercourse, one of the common practices among the gay men, carries a significant risk of HIV and STDs transmission if it is conducted without condoms. The thin mucous membrane lining the anus and rectum makes it much easier for different viruses to find a way to enter the body. You may counsel your patients on safer sex practices and the importance of using condoms and lubricant in anal sex and oral sex. Depression or anxiety due to social pressure 2 Stigma and discrimination towards gay men creates a hostile social environment that causes a high prevalence of depression and anxiety in the gay community. Due to the social pressure regarding disclosing their sexual orientation, many gay men may have internalized stigma and find it difficult to disclose their sexual orientation to the healthcare providers. Some of them may not even identify themselves as gay men even when they have experienced same-sex sexual contact. Substance use 3 Substance use is common for some gay people. This includes substances ranging from crystal methamphetamine (ice), to viagra, ketamine and amyl nitrate (poppers). 40% of the gay men would not go for HIV testing for fear of disclosing their sexual identity. You may support your patients by conducting consultation in a non-judgmental way and make them feel safe in disclosing their sexual orientation or sexual practices. 13% the prevalence of substance abuse is 13% among the gay people. 2 The use of recreational drugs may decrease awareness of safer sex practices and increases the risk of HIV infection. More on the Hong Kong HIV epidemic The HIV epidemic is rising sharply in recent years. There are 2 new cases of HIV infection every day in Hong Kong. 8 Over 50% of newly diagnosed cases acquired the infection via homosexual contact. Antiretroviral therapy (also known as cocktail therapy) can now effectively suppress the virus. Generally, HIV virus does not have a devastating impact on people s health and life expectancy if medication is taken regularly. 9

7 Particular Health Concerns of Lesbian Patients Sexually transmitted disease Lesbians can get the same sexually transmitted infections (STIs) as heterosexual women. Although lesbians are at lower risk of transmitting HIV, they can give each other STDs like herpes, gonorrhea and chlamydia by vaginal-vaginal contact, oral sex, digital vaginal or anal contact, and sharing of sex toys. Therefore, it is important to avoid presuming the sexual acts all women experience are heterosexual contact. When you have to ask about the patients sexual history, it is better to ask Have you ever had sex recently, regardless of the gender of your sexual partner? instead of asking whether they have boyfriends or husbands. The awareness of safer sex practices is generally low among lesbians. Therefore, you can also advise your patient to practice safer sex by cleaning sex toys before and after use, use finger condoms (available in sex shops) during digital penetration, and have a small piece of latex during oral sex. 60% of the lesbians never 3 conduct safer sex practices. Smoking and Cancer Local evidence shows that lesbians are more likely to develop lung cancer than the general female population. The viruses that cause cervical cancer can be sexually transmitted between women as well. However, most lesbians underestimate the risk of their same-sex behavior. Mental health and domestic violence Lesbians may suffer from intimate partner violence just like any other heterosexual women, including physical violence, psychological abuse, sexual abuse, and different forms of threats or manipulative behavior. These acts of violence would cause serious mental and physical trauma on the battered lesbians. 63% of the lesbians reported to be current smokers. 4 Lesbians are more likely to develop breast, endometrial, and ovarian cancers, as they may not experience the full-term pregnancy some heterosexual women have that naturally protect them from these cancers. Hormones released during pregnancy and breastfeeding are thought to protect women against these cancers. Only 13.8% of the lesbians get routine pap 4 tests to detect cervical cancer. 49.9% of the homosexuals have suffered from domestic violence. 5 Studies have shown that lesbians suffer from more serious intimate partner violence than gay men because they seldom fight back when they are attacked. While the forms of violence against homosexuals and heterosexuals might be similar, some factors that contribute to same-sex domestic violence are unique. For example, a lesbian might be threatened to stay in the abusive relationship for fear of having her sexual orientation revealed to significant others or being unable to find another partner in the community

8 Dispelling Myths Be aware of the healthcare issues and culture of the gay community, but do not assume that they are all the same! 3. Are all gay men effeminate? Are all lesbians masculine? The term gay is often associated with sissy and effeminacy. It is true that some gay men may cross dress and do not exhibit traditional heterosexual male behavior. However, the majority of gay people do not see themselves as feminine. Many of them are indeed very masculine. Similarly, not all lesbians exhibit male behavior or dress like a man. A person s gender expression (whether he/she is feminine or masculine) has nothing to do with their sexual orientation. You cannot assume the guy is gay or straight by their career, appearance or behavior alone. 4. Do all gay men or lesbians have multiple sex partners? With reference to the statistics by AIMSS in 2010, 24% of gay men only have one single sex partner in the past 6 months. Like heterosexuals, some gay men and lesbians have multiple partners, some have one partner, and some go through periods without any partners. Therefore, try not to make hasty assumptions on the type of sexual relations your clients have based on their sexual orientation. When you need to ask questions regarding the patients sexual health, remember to focus on sexual practices rather than their sexual orientation. 1. Are all gay men related to the transmission of HIV? The latest figure from HARiS in 2014 shows the prevalence of HIV is 5.85% among gay men, which is higher than that of the general public. However, transmission of HIV is related to unsafe sex practices and has nothing to do with sexual orientation. Anyone who engages in unsafe sex runs the risk of being infected with HIV. 2. Do all gay men perform anal sex? According to the Asia Internet MSM Sex Survey (AIMSS, 2010) in Hong Kong, 64.5% of gay men had performed anal sex in the past 6 months, and 15% of the respondents indicated that they have never tried anal sex in their whole lifetime. On the other hand, some heterosexuals may perform anal sex. According to the research by Centers for Disease Control and Prevention (CDC), 40% of men and 35% of women between 25 and 44 had engaged in heterosexual anal sex. Gay Slang 1/0/10 (Top/Bottom/Versatile) 1/0/10 (Top/Bottom/Versatile) is the gay slang that describes the sex positions in anal sex. A 1/Top is usually the person who engages in penetrative role during anal sex; while 0/Bottom is usually the one who receives penetration. A 10/Versatile is the guy who is open to both insertive and receptive anal sex

9 Sauna Sauna is a gay cruising venue. Apart from being an entertainment venue where they could relax, sauna is also a venue where gay men look for sex with other guys. Condoms and lubricant are usually provided in the dark rooms and private cabins. Chem Fun/Party and Play (PNP) Some gay men have the habit of taking recreational drugs during sex to experience more sexual pleasure. They would call it party and play (PNP) or chem fun, which may last for many hours and many include different high-risk sexual behaviors, like bareback (no condoms) and group sex. Member The term homo comes from people outside the gay circle. In the gay community, this term is not often used, and some gay men may not feel comfortable about being called homo. They usually name themselves as member. TB/TBG/Pure/No label/bi A TB (Tomboy) is usually a lesbian who exhibits male behavior or dresses like a man. TBG is a lesbian who is attracted to TB and exhibits comparatively feminine behavior. There are also some lesbians who are feminine, and are attracted to feminine lesbians, which people call pure relationship. No label means a lesbian who does not consider herself to fall into the stereotypical categories of TB, TBG or Pure. Bi is the abbreviation for bisexual. 1. HIV and AIDS Response Indicators Survey (HARiS) 2. Asia Internet MSM Sex Survey (AIMSS) 3. Survey on lesbian safer sex practices by Women Coalition of HKSAR Wu Yingyi (2010). Dissertation of MPH: A cross-sectional kap study on health seeking behavior among lesbians/bisexuals in Hong Kong. Pp Mak Wing Sze (2013) Risk and Protective Factors of Same-Sex Intimate Partner Violence in Hong Kong. J Interpers Violence. 28: Contact AIDS Concern men2men@aidsconcern.org.hk 14

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18 Chem Fun/Party and Play (PNP) Member TB/TBG/Pure/No label/bi 1. HARiS 2. AIMSS Wu Yingyi (2010). Dissertation of MPH: A cross-sectionalkap study on health seeking behavior among lesbians/bisexuals in Hong Kong. Pp men2men@aidsconcern.org.hk 14

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e-A5booklet_jan 01 03 08 06 09 1 12.5% 40% 2 3 1 2 5 3 4 1 2 3 4 4 5 3 7 6 1 13% 50% 2 45% 2014 5.85% 1 6% 2010 2 2 3. 4. 1. 2. 1/0/10 8 9 Table of Contents Why the Dr. Rainbow Scheme? Why should I join the Dr. Rainbow