The Health Hazards of “Don’t Ask, Don’t Tell:” A View from the Clinic

Kenneth Katz

“Don’t ask, don’t tell” is a giant roadblock in the middle of the typical “ask” and “tell” encounter that’s absolutely essential to the effective practice of medicine. Don’t we owe it to our men and women in uniform, who are called on to sacrifice so much for us every day, to make sure we’re doing our part to protect their health?

This article was amended at 12:48 p.m. Friday, December 3rd, 2010 to fix a typo in this sentence in the last paragraph, which now reads correctly as follows:

The sailor also told me he would not return to see me for retesting for gonorrhea in three months, as I recommended, following CDC guidelines. He was, he explained, about to be deployed on a combat mission in Afghanistan.

On December 1, The New England Journal of Medicine published an article I wrote entitled “Health Hazards of ‘Don’t Ask, Don’t Tell.’” The article describes how the military’s policy on homosexuality imperils the health of service members, the military, and the country, and it advocates for repeal of the policy on those grounds.

I have to say that, until last year, I never anticipated publishing an article about “don’t ask, don’t tell.” I have always supported repeal of the policy. But I’m a physician and public-health practitioner, not a policy wonk, lawyer, or expert on military affairs. And I’ve never served in the military myself.

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What changed? Well, in 2009 I moved to San Diego, California, to take a job as medical director of the municipal STD clinics in San Diego and as director of public health efforts to prevent and control STDs in the community. San Diego has proved different from places I’ve lived in the past. It’s not just sunnier. It’s a whole lot more military. In fact, about 175,000 active-duty service members and their dependents live in San Diego. And considering that an estimated 2.2 percent of military personnel are lesbian, gay, or bisexual (LGB), it should not be a surprise that a fair number of them are LGB.

I know that first-hand, because I frequently care for active-duty service members, including LGB service members, in the municipal clinics. And, as I do for every patient I see, I take a sexual history. I ask my patients who they have sex with, what types of sex they’re having with their partners, whether they’re using protection. In doing so, I’m simply doing what I’ve been trained to so since my very first day of medical school: find out what the problem is, and fix it. And, when it comes to sexual health, those questions are critical to me, in determining which screening tests to order, which diagnoses to consider, and which STD and HIV prevention messages I should provide. For example, guidelines from the Centers for Disease Control and Prevention (CDC) regarding STD screening are different for men who have sex with men who than they are for men who have sex only with women.

What happens when I ask my patients those intimate questions? Well, for the most part, whether my patients are men or women, gay or straight, military or civilian, they tell. They know that I need that information to help them. And they want to be helped. They want to be – or stay – healthy, after all. That’s why they came to see me in the first place.

The problem with “don’t ask, don’t tell” is that it’s a giant roadblock in the middle of the typical “ask” and “tell” encounter that’s absolutely essential to the effective practice of medicine. It’s like trying to take care of a patient with chest pain without being able to ask him whether he smokes, or has a history of heart disease, or has ever had a heart attack in the past. It’s not good medicine.

But, unfortunately, that’s exactly what happens in many military healthcare settings, according to scores of military clinicians and service members with whom I’ve talked. Military clinicians don’t ask, and service members don’t tell. No matter that the Department of Defense last year exempted use of disclosures of same-sex sexual behavior from use under “don’t ask, don’t tell” procedures. Many military clinicians and service members I’ve talked to aren’t aware of that exemption. Even after I tell them about it, military clinicians and service members say they still won’t ask and won’t tell. As one military physician wrote me after reading my article: “Training in military medicine will also have to change with the times because I/we have never been previously trained in taking appropriate sexual histories.”

The upshot is that infections among service members go undiagnosed and untreated – unless they come see me, or another civilian provider proficient in sexual health. There are certainly many more service members who don’t know about, or don’t have access to, municipal clinics. In those cases, we all lose. If infections go undiagnosed and untreated, our public health efforts to break the chain of transmission of STDs and HIV are undermined. That goes for our efforts in both the military and the civilian populations, which in San Diego, and many other areas across the country, have a huge amount of social – and sexual — overlap.

STDs, of course, compromise military readiness, whether they’re among LGB service members or not. And they also predispose to HIV acquisition, which itself is unfortunate for a service member and costly, in terms of readiness and healthcare expenses, for the military.

The best way to make sure our service members stay healthy is to remove the “don’t’ ask, don’t tell” roadblock. Repealing “don’t ask, don’t tell” will have health benefits for service members, the military, and the country. Don’t we owe it to our men and women in uniform, who are called on to sacrifice so much for us every day, to make sure we’re doing our part to protect their health?

The Department of Defense this week released survey results indicating that 70 percent of service members say that repeal of “don’t ask, don’t tell” would have positive or mixed impact, or no impact at all, on their units. And there’s some hope that the U.S. Senate will vote on repeal of the policy before the lame duck session ends this month.

But in the meantime, active-duty service members continue to come to the municipal clinics. They include people like the sailor I describe in The New England Journal of Medicine, a gay man I diagnosed with an STD. He would never, he told me, go to a military clinic with a problem like that, so long as “don’t ask, don’t tell” was the law of the land. Doing so would pose too great a risk to his career.  The sailor also told me he would not return to see me for retesting for gonorrhea in three months, as I recommended, following CDC guidelines. He was, he explained, about to be deployed on a combat mission in Afghanistan.

______________________

Kenneth A. Katz, MD, MSc, MSCE is an Associate Member of the National Coalition of STD Directors (NCSD) and a physician and public-health practitioner in San Diego, California, who focuses on STDs. He is an Associate Adjunct Professor at the Graduate School of Public Health at San Diego State University and a Voluntary Assistant Clinical Professor in the Division of Dermatology at the University of California at San Diego.

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Complaint: Citing Catholic Rules, Doctor Turns Away Bleeding Woman With Dislodged IUD

Amy Littlefield

“It felt heartbreaking,” said Melanie Jones. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

Melanie Jones arrived for her doctor’s appointment bleeding and in pain. Jones, 28, who lives in the Chicago area, had slipped in her bathroom, and suspected the fall had dislodged her copper intrauterine device (IUD).

Her doctor confirmed the IUD was dislodged and had to be removed. But the doctor said she would be unable to remove the IUD, citing Catholic restrictions followed by Mercy Hospital and Medical Center and providers within its system.

“I think my first feeling was shock,” Jones told Rewire in an interview. “I thought that eventually they were going to recognize that my health was the top priority.”

The doctor left Jones to confer with colleagues, before returning to confirm that her “hands [were] tied,” according to two complaints filed by the ACLU of Illinois. Not only could she not help her, the doctor said, but no one in Jones’ health insurance network could remove the IUD, because all of them followed similar restrictions. Mercy, like many Catholic providers, follows directives issued by the U.S. Conference of Catholic Bishops that restrict access to an array of services, including abortion care, tubal ligations, and contraception.

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Some Catholic providers may get around the rules by purporting to prescribe hormonal contraception for acne or heavy periods, rather than for birth control, but in the case of copper IUDs, there is no such pretext available.

“She told Ms. Jones that that process [of switching networks] would take her a month, and that she should feel fortunate because sometimes switching networks takes up to six months or even a year,” the ACLU of Illinois wrote in a pair of complaints filed in late June.

Jones hadn’t even realized her health-care network was Catholic.

Mercy has about nine off-site locations in the Chicago area, including the Dearborn Station office Jones visited, said Eric Rhodes, senior vice president of administrative and professional services. It is part of Trinity Health, one of the largest Catholic health systems in the country.

The ACLU and ACLU of Michigan sued Trinity last year for its “repeated and systematic failure to provide women suffering pregnancy complications with appropriate emergency abortions as required by federal law.” The lawsuit was dismissed but the ACLU has asked for reconsideration.

In a written statement to Rewire, Mercy said, “Generally, our protocol in caring for a woman with a dislodged or troublesome IUD is to offer to remove it.”

Rhodes said Mercy was reviewing its education process on Catholic directives for physicians and residents.

“That act [of removing an IUD] in itself does not violate the directives,” Marty Folan, Mercy’s director of mission integration, told Rewire.

The number of acute care hospitals that are Catholic owned or affiliated has grown by 22 percent over the past 15 years, according to MergerWatch, with one in every six acute care hospital beds now in a Catholic owned or affiliated facility. Women in such hospitals have been turned away while miscarrying and denied tubal ligations.

“We think that people should be aware that they may face limitations on the kind of care they can receive when they go to the doctor based on religious restrictions,” said Lorie Chaiten, director of the women’s and reproductive rights project of the ACLU of Illinois, in a phone interview with Rewire. “It’s really important that the public understand that this is going on and it is going on in a widespread fashion so that people can take whatever steps they need to do to protect themselves.”

Jones left her doctor’s office, still in pain and bleeding. Her options were limited. She couldn’t afford a $1,000 trip to the emergency room, and an urgent care facility was out of the question since her Blue Cross Blue Shield of Illinois insurance policy would only cover treatment within her network—and she had just been told that her entire network followed Catholic restrictions.

Jones, on the advice of a friend, contacted the ACLU of Illinois. Attorneys there advised Jones to call her insurance company and demand they expedite her network change. After five hours of phone calls, Jones was able to see a doctor who removed her IUD, five days after her initial appointment and almost two weeks after she fell in the bathroom.

Before the IUD was removed, Jones suffered from cramps she compared to those she felt after the IUD was first placed, severe enough that she medicated herself to cope with the pain.

She experienced another feeling after being turned away: stigma.

“It felt heartbreaking,” Jones told Rewire. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

The ACLU of Illinois has filed two complaints in Jones’ case: one before the Illinois Department of Human Rights and another with the U.S. Department of Health and Human Services Office for Civil Rights under the anti-discrimination provision of the Affordable Care Act. Chaiten said it’s clear Jones was discriminated against because of her gender.

“We don’t know what Mercy’s policies are, but I would find it hard to believe that if there were a man who was suffering complications from a vasectomy and came to the emergency room, that they would turn him away,” Chaiten said. “This the equivalent of that, right, this is a woman who had an IUD, and because they couldn’t pretend the purpose of the IUD was something other than pregnancy prevention, they told her, ‘We can’t help you.’”

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The Crackdown on L.A.’s Fake Clinics Is Working

Nicole Knight

"Why did we take those steps? Because every day is a day where some number of women could potentially be misinformed about [their] reproductive options," Feuer said. "And therefore every day is a day that a woman's health could be jeopardized."

Three Los Angeles area fake clinics, which were warned last month they were breaking a new state reproductive transparency law, are now in compliance, the city attorney announced Thursday.

Los Angeles City Attorney Mike Feuer said in a press briefing that two of the fake clinics, also known as crisis pregnancy centers, began complying with the law after his office issued notices of violation last month. But it wasn’t until this week, when Feuer’s office threatened court action against the third facility, that it agreed to display the reproductive health information that the law requires.

“Why did we take those steps? Because every day is a day where some number of women could potentially be misinformed about [their] reproductive options,” Feuer said. “And therefore every day is a day that a woman’s health could be jeopardized.”

The facilities, two unlicensed and one licensed fake clinic, are Harbor Pregnancy Help CenterLos Angeles Pregnancy Services, and Pregnancy Counseling Center.

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Feuer said the lawsuit could have carried fines of up to $2,500 each day the facility continued to break the law.

The Reproductive Freedom, Accountability, Comprehensive Care, and Transparency (FACT) Act requires the state’s licensed pregnancy-related centers to display a brief statement with a number to call for access to free and low-cost birth control and abortion care. Unlicensed centers must disclose that they are not medical facilities.

Feuer’s office in May launched a campaign to crack down on violators of the law. His action marked a sharp contrast to some jurisdictions, which are reportedly taking a wait-and-see approach as fake clinics’ challenges to the law wind through the courts.

Federal and state courts have denied requests to temporarily block the law, although appeals are pending before the U.S. Court of Appeals for the Ninth Circuit.

Some 25 fake clinics operate in Los Angeles County, according to a representative of NARAL Pro-Choice California, though firm numbers are hard to come by. Feuer initially issued notices to six Los Angeles area fake clinics in May. Following an investigation, his office warned three clinics last month that they’re breaking the law.

Those three clinics are now complying, Feuer told reporters Thursday. Feuer said his office is still determining whether another fake clinic, Avenues Pregnancy Clinic, is complying with the law.

Fake clinic owners and staffers have slammed the FACT Act, saying they’d rather shut down than refer clients to services they find “morally and ethically objectionable.”

“If you’re a pro-life organization, you’re offering free healthcare to women so the women have a choice other than abortion,” said Matt Bowman, senior counsel with Alliance Defending Freedom, which represents several Los Angeles fake clinics fighting the law in court.

Asked why the clinics have agreed to comply, Bowman reiterated an earlier statement, saying the FACT Act violates his clients’ free speech rights. Forcing faith-based clinics to “communicate messages or promote ideas they disagree with, especially on life-and-death issues like abortion,” violates their “core beliefs,” Bowman said.

Reports of deceit by 91 percent of fake clinics surveyed by NARAL Pro-Choice California helped spur the passage of the FACT Act last October. Until recently, Googling “abortion clinic” might turn up results for a fake clinic that discourages abortion care.

“Put yourself in the position of a young woman who is going to one of these centers … and she comes into this center and she is less than fully informed … of what her choices are,” Feuer said Thursday. “In that state of mind, is she going to make the kind of choice that you’d want your loved one to make?

Rewire last month visited Lost Angeles area fake clinics that are abiding by the FACT Act. Claris Health in West Los Angeles includes the reproductive notice with patient intake forms, while Open Arms Pregnancy Center in the San Fernando Valley has posted the notice in the waiting room.

“To us, it’s a non-issue,” Debi Harvey, the center’s executive director, told Rewire. “We don’t provide abortion, we’re an abortion-alternative organization, we’re very clear on that. But we educate on all options.”

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