Bisexuality and Health

I had a very odd experience at my doctor’s appointment a few weeks ago. Odd enough that I’m going to write about it here even though I’m not sure it ties in neatly to bisexuality; the nice thing about having a platform is that I can write about whatever I consider important.

It was a routine appointment, and I told my doctor that I wanted the full run of STD tests as part of my annual check-up. She started asking me about my sexual behavior, and after ascertaining that I still have the same regular partner as last year and still use barriers for all of the behaviors we discussed last year, she turned to me and said “So what are we doing all of this testing for?” I was understandably taken aback, and just stared at her looking flabbergasted while she launched into a spiel about how people having safer sex within the context of a monogamous relationship just don’t need yearly testing. Granted, this doctor seems to have a pretty strict idea of what constitutes safer sex (she asked me quite earnestly when the last time was that I’d had someone else’s fingers in my mouth without a latex glove, and insisted that even boiled silicone toys should have condoms on them – maybe she means monogamous couple who wear hazmat suits with each other?), but still, let’s back up a little. When did doctors start discouraging patients from having yearly STI testing? Seriously? And this is not an isolated incident. I’d already heard a friend or two say that her doctor thought she wasn’t at risk and didn’t need to be tested. And when I went around in a haze of disbelief telling people about this crazy thing my doctor said, many of them told me they’d had the same experience.

I can think of so many problems with this strategy. What happened to the constant push to get tested? I still get that from the ubiquitous ads telling me to know my status, and from my peers in my fairly slutty, sex-positive, very risk-aware subcultures — from pretty much all of the cultural sources I come in contact with. But not, apparently, from my doctor. My doctor at the LGBT health center, no less. This is a place that offers Herpes 1 and 2 testing as part of its basic testing procedure and has fliers on its walls advertising countless support groups for folks who are HIV+. If anyone is going to be on top of encouraging everyone to get tested, I’d expect it to be the doctors here. And it hardly matters that I was able to convince my doctor that I actually needed the tests, or that I probably could have had them by insisting even if I hadn’t convinced her. The important thing is that many people trust their doctors, and go to them as their main source of not only medical care but also medical information and advice. If advising people not to get tested is a general trend in medicine right now, there are probably a lot of people out there listening and not getting tested.

What I really don’t get is who this advice benefits. What’s to lose in getting tested, and how can it possibly compare to the risks involved with *not* being certain of your status? A few dollars of lab work, versus the damage an undetected and untreated STI can cause; we all know about HIV, syphillis involves stark raving madness before it kills you, and even the easily-cured gonorrhea can lead to infertility if left alone. Even for money-grubbing insurance companies, it should be clear that prevention and early detection are significantly cheaper than late-stage treatment. And I’m having trouble thinking of rationales for this other than insurance companies leaning on doctors to order fewer expensive tests. (Also, they’re not expensive. I just paid for my own, and if I hadn’t tested for Herpes 1, all the rest would have come to $60.)

‘Cause it’s just not true that people in monogamous couples don’t need yearly testing. I haven’t been keeping track of the men, but nearly all of the women I know who’ve contracted STIs have done so while in what they believed to be monogamous relationships. I’m all for trusting your partner, but I’m also all for taking care of yourself — you’re not with your partner all the time, you don’t know what ze does or doesn’t do when you’re not there (or what protection ze does or doesn’t use while doing it). I don’t think this should keep people from trusting others enough to have relationships — or even enough to be fluid bonded, though that’s a harder one for me — but it should certainly mean getting tested. Because you can be a lot more sure of your test results than you can be of what’s happening when you’re not around. I’m utterly confused as to why doctors wouldn’t take that into account when advising on testing.

The other thing I would expect them to take into account is the fact that people don’t tell their doctors everything. When my doctor asked why we were doing all of this testing and I said because it had been a year and that’s what you do, that could easily have been the last thing I said. I didn’t have to tell her that I’m in a nonmonogamous relationship and prone to casual sex — hell, I had to interrupt her spiel on the safety of monogamous relationships to do so. And what if I was in a nominally monogamous relationship but I was cheating? While I might not feel the need to point that out, it would certainly affect my level of risk. What if I shared needles? She might have asked me about that if my answers about drug use indicated the need, but I bet drug use is another thing people routinely lie to their doctors about. As, come to think of it, is sexual orientation; particularly lies of omission. What bits are involved can affect how risky sex is and how likely people are to use barriers, whether it’s men not using condoms with other men because they can’t get knocked up, cis women not using barriers with other cis women because it’s so much less risky than sex with penises, or not being prepared because you’re sneaking out doing something counter than your claimed identity and having protection on hand would mean admitting to yourself that you’re about to do it. My doctor asked my orientation (last year), but how many outside the LGBT health center do? And how may patients outside the LGBT health center hesitate to answer honestly? Not to mention the countless people whose identities don’t give you the whole picture on their behaviors (I know lots of dyke-identified people who have sex with men, and not a few fags who have sex with women – I’d probably know similar straight people, except I don’t know many straight people these days). And the faulty assumption that people sleeping with only women or only men will always encounter the same sets of bits and have the same sorts of sex with them. “Are you having sex with men?” is a totally different question from “Are you having intercourse?,” so if that’s the information doctors want, they may not always be getting it accurately.

And while I’m writing about bisexuality and health (and about withholding information from one’s doctor), there’s something I’m sure ties in to bisexuality quite neatly. Girlfriend, Esq. and my Google alerts both pointed me toward this report on bisexuality and health (read the report itself as a .pdf here). I want to take a moment to object to their statement that “Lesbian/homosexual women were more likely to be obese versus at a ‘normal’ weight compared to straight/heterosexual women” as a statement of health. Evidence that lower weight equals better health are much more uncertain than the medical establishment would have us believe, and it’s been theorized that higher weights among lesbians could have to do with lesbians being more likely than straight men to find a wider range of body types attractive, thus putting less pressure on queer women to hate their bodies and try to lose weight (and you know what’s unhealthy? Self-hatred and yo-yo dieting). But the medical establishment’s fatphobia aside, it’s an interesting report. Apparently gays and lesbians are measurably less healthy than straight people in a number of areas (“self-reported health; disability-related activity limitation; asthma; current and past tobacco smoking; anxious mood; 30-day binge drinking and substance use; and lifetime sexual assault victimazation.”), and bisexuals are even worse off (“access to health insurance, as well as medical and dental providers; heart disease; anxious and depressed moods, 12-month suicidal ideation; current tobacco smoking, and lifetime and 12-month sexual assault victimization. In addition, bisexual women were more likely to report disability-related activity limitation, 30-day illicit drug use, and lifetime intimate partner violence victimization”). I’ve been hearing speculation along those lines for a long time, but maybe having an actual study to point to will catalyze people a little more to figure out what’s going wrong here and fix it. (On the bright side, queers are more likely to have ever been tested for HIV, and gay men are more likely to have gotten colorectal cancer screenings, and to report recent condom use.)

Of course, we could always follow this guy’s advice and simply stop having all of that queer sex. That would clear the problem up for sure. No gays, no measurable health disparity! ‘Cause it’s definitely actual homosexual behaviors that are leading to poor health. It’s not that queers are likely to have lower incomes and less support from their families, and therefore less access to both health insurance and medical care – even though this study itself says that bisexuals have less access to health insurance and are less likely to have a regular healthcare provider, and those two things in and of themselves could explain a lot of health disparities. It’s not that homophobic doctors might be consiously or unconsciously be providing a lower quality of care to queer patients, or that queers are not coming out to their doctors for fear of that and therefore aren’t getting healthcare that’s really targeted for them. It’s not a lack of training and education on how healthcare could be targeted for us. There’s no way that the extra stress and despair of life in the closet or of facing individual and systemic homophobia affect health generally and specifically lead to more self-harming behaviors like drinking, smoking, and drugs. No, none of that. It’s the evil of our ways manifesting in our bodies, for sure. And forcing us back into the closet definitely won’t make the problem worse.

I wonder what “strategies to reduce the number of gays, lesbians and bisexuals” he thinks the Department of Health, Governor, and Legislature have come up with, since everything from McCarthy-era witch hunts to concentration camps to, oh, believing the lifestyle is inherently evil and unhealthy has failed in the past, and those pesky gays, lesbians, and bisexuals still insist on engaging in their unhealthy gay, lesbian, and bisexual behaviors. Here’s a nice rebuttal.

5 Responses to “Bisexuality and Health”

  1. 16 December 2008 at 10:49 am

    The first time I went for my annual GYN visit (about four years after I started having sex because I was in an abusive relationship which going to the GYN prior to 18 would have outed) was at my university’s health services department. They actually have a decent intake form, which unfortunately doesn’t ask about gender identity but does ask about number and sex of partners.

    But my doctor apparently didn’t look at my form.

    She asked me about birth control, a routine question. “None.”
    With a slightly concerned look on her face, she asked about condom use, another routine question. “Nope.”
    Horrified, she turns to me aghast and starts explaining the dangers of pregnancy and STIs. Which I had to interrupt with “I don’t have sex with penises.”
    She said “…oh,” and didn’t say anything for a little while, before going on with the exam. After it was over, she left saying “And don’t forget to use condoms…um…on any toys.”

    All of this at my first exam, when I am for all intents and purposes naked on the freaking table, which really sucks even when you’re cis and is even more awkward when you’re trans. And if she’d bothered to read the damn form beforehand I might’ve been spared some of the embarrassment.

    *cough* Anyway, it is ridiculous for a doctor to tell you that you don’t have to be tested. Even if it says “married” on your form, that doesn’t mean you’re necessarily monogamous, or that your partner/s are, either ethically or deceitfully. The doctor doesn’t make the same trust and risk-assessment decisions that you do–you or your partner/s could be concealing or misrepresenting any information for any reason. Not to mention cisboys are generally asymptomatic for several unpleasant STIs, and female-bodied people aren’t guaranteed to have visible symptoms either.

    Best practices should always be to test rather than not. And if everyone is tested on a regular basis, no one group is targeted based on its “risky behaviors” or given a pass because of cultural assumptions of reputability. I would bet a white doctor would recommend a Black or Latina woman be tested even if she were in an ostensibly monogamous relationship, more often than said doctor would a white woman professing the same circumstances. And doctors routinely tell lesbians they only need to go to the GYN every three years.

  2. 2 Lee
    16 December 2008 at 12:50 pm

    And I’m having trouble thinking of rationales for this other than insurance companies leaning on doctors to order fewer expensive tests. (Also, they’re not expensive. I just paid for my own, and if I hadn’t tested for Herpes 1, all the rest would have come to $60.)

    I’m going to bet that those low costs are due at least in part to some of the testing being done for free through the health dept. The clinic may also receive discount pricing from LabCorps and/or Quest due to being a non-profit or a health care provider of last resort.

    Our health department leans on us not to do testing on women over thirty unless they have symptoms or specific risk factors. I’m sure they wish they did, but they don’t have the money and resources to actually process universal testing.

    The actual lab fees for a full STI panel without the benefit of health departments and discount contracts with private labs comes to around $250 give or take $30 (depending on the exact types and methods of testing done).

    Which is not to say that I think we should stop screening people without obvious risk factors — I think we need to find the money to screen them.

  3. 3 Aviva
    16 December 2008 at 2:46 pm

    Lee,you’re probably right. Everything else at the clinic is on a sliding scale, I’m sure the testing was too. And even so, HSV 1 cost as much as the rest of the tests put together. Thanks for the look inside what could be driving this.

  4. 17 December 2008 at 10:02 pm

    I couldn’t agree more with everything you’ve said here.
    For years I was pissed off as doctor after doctor discouraged me from getting pap smears regularly. You’re a lesbian whose in a longterm monogamous relationship? Come back in 3-5 years! You might be interested in this, which discusses, among other things, that women who have sex with women are just as much at risk of STDs as straight women.

    It continues to shock me that doctors chose to act as though people in nominally monogamous relationship don’t have sex with others who are not their partners,or that some people would feel too much shame to admit these things. Honestly, I think that for economic reasons they chose not to look at these issues.

    Great post!

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