Beyond Diagnosis and Treatment

Since the 1800s, the debate about the pathology of homosexuality has occupied center stage in the relationship between homosexuality and medicine. That focus notwithstanding, the vast majority of homosexual men and women never wanted, sought, or received therapy for their sexual orientation. Each one of these men and women has, however, other healthcare needs. At the very least, males who have sex with males and females who have sex with females have specific risks to their health, and this is especially true for homosexual youth who seem to be at increased risk of suicide (Gibson). Against this background, it is important to ask whether health professionals have the knowledge and communication skills necessary to meet the health needs of this group. Certainly some health professionals and academic commentators have paid attention to the healthcare needs of homosexual people (Solarz). However, medicine's own history in regard to homosexuality can stand in the way of appropriate degrees of study and effective healthcare.

No matter what their sexual interests, patients already face a problematic relationship with healthcare: medicine is distant from them by reason of its complex and intricate knowledge, cultural expectations about the role of the physician, and professional commitments within medicine (Engelhardt, p. 291). People with same-sex interests are perhaps at a further disadvantage because they cannot uniformly expect to encounter healthcare practitioners who are conversant with the specific health risks of homosexual men and women and who are comfortable with the nature of their sexual lives.

Indeed, some practitioners may believe that health risks associated with homosexuality are deserved and therefore require less social attention than other problems. In the 1980s, for example, some commentators argued that the AIDS epidemic was a divine punishment for immoral homosexuality. This view is hard to credit for a variety of reasons. In the first place, the view is suspect because the "punishment" is applied inconsistently. Some men who have sex with other men have developed AIDS, but most others—across history and even in the present—have not. Further, why should homosexuality receive this sort of punishment while other moral transgressions go unpunished? How is the punishment proportionate in its effect, and why should consensual behavior be punished so severely?

Rather than tie AIDS to divine punishment, some commentators pointed to social injustice as a root cause of the epidemic. These commentators argue that the sexual behavior of many homosexual men is affected by social prejudice. In other words, some men take sexual risks as adverse preferences, something they would not do if they had the same array of options in relationships and social status as others. Because they do not, they make poorer choices. According to these commentators, society has an obligation to make amends to those whose disease can be traced back to social inequality (Mohr).

Are there social factors that stand in the way of the health of homosexual men, women, and adolescents? One factor might be obstacles to the formation of long-term relationships and families that are especially important when it comes to healthcare and caregiving. Some homosexual people have no access to health insurance through their partner's employment, as married partners have, and others have no presumptive right of inheritance or decision making at the bedside of a partner who cannot direct his or her medical choices. The law does allow homosexual men and women to make health decisions for their partners who lose the ability to do so, but this recognition ordinarily requires advance directives such as a power-of-attorney for healthcare. When such arrangements are not put in place, some partners are excluded from decision making. Some healthcare services are not available to homosexual people. Some commentators think infertility clinics should not offer services to people in same-sex relationships, and some clinics do exactly that (Ford). For reasons like these, it is certainly worth asking whether deficits in the health and well-being of homosexual men and women are rooted in social injustice, with injustice minimally defined as the social failure to treat like cases alike.

Patients are not the only people in healthcare relationships, of course, and it is important to note that many gay and lesbian health professionals—physicians, nurses, and others—believe that certain social attitudes work against their full acceptance in the medical community. For example, some residency directors do not wish to have homosexuals in their graduate training programs. These hurdles may not have the same force everywhere and for everyone, but they nevertheless work against the equal standing of gay, lesbian, and bisexual healthcare practitioners (Potter).

The debate about the ethics of homosexuality has extended into discussions about cloned human beings. Some commentators have argued broadly that no one— single people, coupled partners, or married people—ought to use cloning to have children (President's Council on Bioethics). Others open the door to the use of cloning by some infertile couples and would allow same-sex female couples to use cloning technologies if they become safe and effective, since these couples have fewer options available to them. Still other commentators have argued that if cloning technology is safe and effective, there is no obvious reason why all same-sex couples should not have access to it. In cloning, as in other aspects of social and moral life, unwritten ethical rules and social opinion often guide the application of biomedical technologies and the distribution of healthcare benefits. When it comes to homosexuality and healthcare, it is often these unwritten rules of social opinion that are decisive and most in need of analysis.

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