Self-Disclosing Sexual Preference as a Health Care Professional
I am an audiologist who works in a teaching hospital where student practicums are common. Within the last few years, a student I was supervising asked me a complex ethical question about a dilemma he was having. This student, who will be referred to as “Ryan” (name protected), disclosed to me that he was gay and was finding it uncomfortable when patients asked him if he had a girlfriend or if he was married. He said he was proud of who he was and did not want to lie to patients about his personal life. His ethical dilemma was whether or not he should disclose to his patients that he is gay. My response to his question was instant at the time. I told him that his first and foremost agenda as an audiologist was to his patients. I said that the act of disclosing personal information about yourself, whether it is religious, political, or personal has the potential risk of affecting your ability to establish and maintain a professional relationship and to counsel, and may undermine the patient’s clinical progress. I said since he does not know which of his patients harbor homophobic attitudes, he should wear a kind of mask and only disclose any personal information when it is intended to help the patient in some way. I advised him not to lie, but to try to sidestep the question of whether or not he has a girlfriend to be on the safe side. Since our conversation about this topic, I have often wondered if I had given him the right advice.
To examine this topic more carefully, more questions need to be answered. What is the impact of homophobia in a health care setting? What are the advantages and disadvantages of self-disclosure? Do audiologists have the right to their own personal privacy? If Ryan sidesteps the question about his personal life, does it contribute to societal homophobic attitudes? What about serving patients who are LGBTQIA? What do the ASHA, ADA, AAA, or SAC Code of Ethics state about this ethical dilemma?
Homophobia in Health Care
Homosexuality was listed as a pathologic disorder in the Diagnostic and Statistical Manual of Mental Disorders until 1973.1 According to the 2010 Hate Crimes statistics released by the FBI National Press Office, 19.3% of hate crimes across the United States were connected to sexual orientation bias.2 With regards to patient perceptions, a study examining the attitudes towards “GLB” physicians in 1998 reported that of the 346 respondents, 11.8% said they would refuse to see a “GLB” physician. The two most common reasons for the discrimination were the respondents thought the physician would be incompetent and they would feel uncomfortable having a “GLB” physician. The proportion of respondents who discriminated was equal across male and female respondents and increased with age.3 Another study in 2008 reported that 30% of the 502 patient respondents would change doctors if they knew the doctor was gay, and more than 35% would change providers if they knew that gay clinicians were employed at the site where they received care.4 These studies highlight that homophobia is a significant discrimination which occurs in the health care setting towards health care workers.
Self-disclosure to patients raises numerous boundary issues involving potential or actual conflicts of interest in relationships with patients. Not all forms of self-disclosure are problematic and unethical, but some are.5 Lussier and Richard discuss the advantages and disadvantages of self-disclosure during medical encounters. They report the advantages of self-disclosure are that it may improve patient support, create a greater sense of closeness, help patients reveal distress they would not otherwise express, reinforce patients’ motivation by providing them with a model, create a special bond, and develop a mutually trusting relationship. The disadvantages are that it could expand the professional relationship into a personal and potentially intimate one, create risk of having to deal with demands not related to the consultation, foster strong emotions that might require management, open the door to undesirable behaviour, provoke too much curiosity about physicians’ personal lives, and create a risk of psychological dependence.6
It is interesting to note that a study was done examining sexual behaviour by patients.155 students and graduates were surveyed and it was found, without revealing anything about themselves, 71% of females and 29% of male medical students report having been the object of sexual advances by a patient at least once during their training.7 This is certainly something to consider when discussing any personal relationship question from patients.
Dr. Ng, who wrote an article about whether or not a gay physician in a small community should disclose his sexual orientation, reports that there is no existing legal provision for personal privacy for physicians probably because it does not relate to performance. He states there is no reason to believe that a physician’s sexual orientation would impact job performance. He said the main risk is that it could affect some patients’ perceived comfort and health behaviours, especially those who are more conservative.8
I thought part of Ryan’s ethical question about self-disclosure stemmed from a desire to not perpetuate homophobic attitudes by hiding the truth about himself. General attitudes about homosexuality in the U.S. and abroad still invoke discrimination in a large number of people as is illustrated by the two polls linked below.
Dr. Jennifer Potter writes about her personal experiences as a lesbian patient and doctor to illustrate the importance of creating an environment in which patients can disclose their sexual orientation and she discusses the challenges and rewards of coming out as a gay physician. In disclosing to her patients, she reports, “it allows me to be myself, to integrate my public and private lives, to voice my opinion and celebrate all of my achievements, and work passionately to increase tolerance and acceptance.”10
Patients who are LGBT
A study by Kelly and Robinson in 2011 examined potential barriers to seeking services for communication impairments by the “LGBT” (lesbian, gay, bisexual, and transgender) community. A clinical survey examined the rate and importance of disclosure of membership in the “LGBT” community by people with communication impairments to their clinicians and the perception of bias of audiologists against “LGBT” individuals with communication impairments. Results showed that the majority of respondents did not disclose their membership in the “LGBT” community even though they felt it was important. Most respondents reported perceiving bias toward a heterosexual orientation from their clinicians.9 I think the results of this study highlight the importance for all audiologists to create a clinical environment where patients feel comfortable talking about their membership in the “LGBTQIA” community.
Code of Ethics
Four national codes of ethics for audiologists are AAA, ADA, ASHA, and SAC.11−14 All four have similar rules in that individuals shall not discriminate in the delivery of professional services on the basis of sex, gender, gender identity or gender expression; ADA (principle 1; rule 6), ASHA (principle 1; rule c), AAA (principle 1; rule 1b), SAC (standard 7; rule a). These rules state audiologists should not discriminate against patients who are LGBTQIA. None of the codes specifically mention self-disclosure by the clinician of sexual orientation or potential discrimination by the patient.
ASHA and AAA code of ethics report that individuals shall not participate in activities that constitute a conflict of professional interest; ASHA (principle III; rule b); AAA (principle 4; rule 4c). ADA reports members shall provide only those procedures, products, and services that, according to the member’s best professional judgment are in the best interest interests of the patient (principle III; rule 2). SAC reports to be vigilant in avoiding activities that may be construed as a conflict of interest and to ensure that the provision of professional services takes priority over personal interests, aims and opinions (standard 17; rule a/c).This raises two vital questions that are not specifically addressed in any of the national U.S. or Canadian code of ethics. What topic(s) of discussion or displays of religious or political symbols of expression constitutes a conflict of interest as it relates to clinician self-disclosure? If the answer to this question is up to each audiologist, what protection from the code of ethics do audiologists have against legal action from patients if they interpret some form of self-disclosure (e.g., conversation or symbol worn) as offensive?
Reflecting back on my initial answer to Ryan, I maintain that an audiologists’ primary obligation is to “do no harm” by protecting the patient and avoiding self-disclosure that has the potential to undermine the patients’ quality of care. That being said, if I could go back in time, I would also mention to “Ryan” that this may not always be case. Patients who disclose they are LGBTQIA in particular may benefit from being seen by a clinician who is also part of the LGBTQIA community so self-disclosure may be appropriate at times, with caution. From researching this ethical dilemma, I have learned that creating an environment that is welcoming to the LGBTQIA community is very important and includes being open to discussing these issues between a supervisor and student and using appropriate language in the workplace that does not perpetuate a stereotypical “heterosexual” bias. There is no easy answer − “Ryan” will have to balance several values with every patient: what is best for the patient, being consistent/ truthful with his own personal values, and his own professional and personal safety. I am hopeful in the future that the discrimination some people display towards the LGBTQIA community will end and this ethical dilemma discussed will be less of an issue.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edition revised. Washington, DC: Author; 2000.
- Federal Bureau of Investigations. FBI releases 2010 Hate Crime Statistics. Washington, DC: Author; 2010. Available at: http://www.fbi.gov/news/pressrel/press-releases/fbi-releases-2010-hate-crime-statistics.
- Druzin P, Shrier, I, Yacowar M, Rossignol M. Discrimination against gay, lesbian and bisexual family physicians by patients. CMAJ 1998;158(5):593–97.
- Lee RS, Melhado TV, Chacko KM, et al. The dilemma of disclosure: patient perspectives on gay and lesbian providers. J Gen Intern Med 2008:23(2):142–47.
- Reamer FG. Eye on ethics. Soc Work Today 2006. Available at: http://www.socialworktoday.com/news/eoe_1106.shtml.
- Lussier MT and Richard C. Self-disclosure during medical encounters. Can Fam Phys 2007;53:421–22.
- Schulte HM, Kay J. Medical students’ perception of patient-initiated sexual behavior. Acad Med 1994;69:842–6.
- Ng H. Should a gay physician in a small community disclose his sexual orientation? Virtual Mentor. August 2010;12(8):613–17.
- Kelly RJ and Robinson GC. Disclosure of membership in the lesbian, gay, bisexual, and transgender community by individuals with communication impairments: a preliminary web-based survey. AM J Speech Lang Pathol 2011 May;20(2):86–94.
- Potter JE. Do ask, do tell. Ann Intern Med 2002;137(5 part 1):341–43.
- American Speech-Language-Hearing Association. Code of ethics [Ethics]; 2010. Available at: < ahref="http://www.asha.org/policy/" taret="_blank">www.asha.org/policy.
- American Academy of Audiology. Code of ethics. Reston, VA: Author; 2011. Available at: http://www.audiology.org/publications-resources/document-library/code-ethics.
- Academy of Doctors of Audiology. Code of ethics. Lexington, KY: Author. Available at: http://www.audiologist.org/academy-documents/code-of-ethics.
- Speech-Language and Audiology Canada. Homepage. Ottawa: ON. Available at: http://www.sac-oac.ca