(The present paper is adapted from two articles which first appeared in San Francisco Medicine, Nov./Dec. 1998, pp. 23-26. A different version is included in Moser, C. (1999) Health Care Without Shame, San Francisco: Greenery Press).
 

Sexual minority is a term used to describe those who identify as other than monogamous heterosexuals. It is specifically thought to include the transgendered, those with multiple sexual partners, sex workers, and S/M practitioners. Physicians and other health care practitioners have just begun to address the special health and lifestyle issues of the gay, lesbian and bisexual patients. However, the medical concerns of other sexual minorities have not been addressed in a meaningful way. The present article is hopefully a beginning for physicians and other health care professionals to address the health concerns and needs of all patients involved in alternative sexual behaviors or lifestyles. [Throughout the present article, the term "physician" will be used to include all health care providers].

The first question healthcare providers need to answer, is whether they really wish to treat such patients. Some physicians are unable to overcome their own personal issues about alternative sexual behaviors and should refer these patients. Even sexual minority physicians may not able to overcome their own issues to treat other sexual minority patients nonjudgmentally. Just because these patients are referred, does not relieve the physician of the responsibility of learning the basics of their care. Most physicians do not speak Mandarin, so it is reasonable to refer new Mandarin-only speaking patients to a Mandarin-speaking physician. Nevertheless, sometimes referral is not an option. When necessary, one should use translators (professional translators, Mandarin speakers who work in the hospital and family members). The physician should also learn something of Chinese culture. Hospitals have devised "Asian diets" (comfort food is important when you are sick) and have made other accommodations. Physicians confronted with sexual lifestyles with which they are not comfortable need to take similar actions: Seek out experts and attempt to make accommodations for patient comfort. If you decide that treating sexual minority patients will be a significant aspect of your practice, the present paper contains some recommendations on how to treat them effectively and respectfully.

Who they are vs. what they do

In treating sexual minority patients, one must distinguish between identity and behavior - a task not as simple as it seems. Individuals may choose a label to define their sexuality, but their actual behavior may be very different. Medical risk is associated with behavior, heredity or environment, not identity. It does not matter whether a male patient identifies as gay, but it does matter if he has sex with men. Additionally, anal sex with a man opens him up to different medical risks than anal sex with a dildo-wielding woman.

Nevertheless, identity is also an issue. A woman who self-defines as a lesbian is often subjected to a variety of stresses that a heterosexual-identified woman is not, without regard to behavior. There are social stressors regarding partner choice ("Will my partner be allowed to visit in the intensive care unit? What will happen when my co-workers meet my lover?"). There are also genuine physical dangers - rape, assault and even homicide - associated with being identified as gay, lesbian, a sex worker, an S/M practitioner, or transgendered, as the crime sheet in any city can attest.

Sexual identity and behavior are fluid. There are people who at different times have defined themselves as gay, straight and bisexual in every possible sequence. It can be hard to imagine, but there are people who at are not quite sure which gender they are, who are frustrated that no one will acknowledge their chosen gender, or who finds any gender at all intolerable. Is a woman who is happily married, but secretly desires sexual contact with other women, a lesbian or bisexual or even heterosexual? Does that orientation change if she begins an affair with another woman, if she leaves her husband, or even if she becomes celibate? There are no simple answers. Just remember that identifying with one sexual orientation, does not describe an individual's actual behavior. Acceptance of this fluidity is the first step in providing nonjudgmental health care and not alienating your patient.

Your sense of the patient's probable identity may not reflect the patient's own self-identification; you are not a mind reader and appearances are deceptive. Be aware that individuals tend to categorize someone into the less societally accepted role, if given the option. A "heterosexual" man who has sex with men is assumed to be a really gay, but a "homosexual" man who has sex with a woman is not assumed to be a really straight. The same phenomenon is even more apparent when applied to other sexual minorities.

No assumptions.

Associating certain medical problems with a specific sexual minority acts to stigmatize that minority. Clearly unprotected anal coitus is a risk factor for HIV transmission, but more heterosexuals take part in anal coitus than homosexuals. The point is; talk with all your patients about anal safer sex practices. The assumption that you can choose whom to advise will unfortunately be proved wrong far too often.

Anal sexuality is often a forgotten area in medical school. Possibly the best piece of advice to give patients interested in exploring anal sex, is to make sure anything inserted into to the anus has a flange to prevent it from being lost in the rectum. A second safety technique that also should be advised is attaching a string to the object. This allows for retrieval if the flange fails to prevent the object from being lost in the rectum. Discussions of how to prevent colonic perforations (smooth soft toys, exceedingly short fingernails, and quick referral for bleeding) should also be emphasized, in addition to safer sex advice. Information about sexually transmitted diseases (STD's) that can be transmitted by anal sex or oral/anal contact should also be reviewed.

Is your office sexual minority friendly?

Your prospective patient's first contact with your practice is your office staff and your forms. Patient information sheets routinely ask questions that may seem simple and routine, but are really quite difficult. Prospective transgendered patients must choose between indicating they are male and female; S/M practitioners must choose between listing their spouse or their S/M mistress as their emergency contact. How does the newly married gay patient indicate that on your forms? A new patient will judge your paperwork, before ever finding out how accepting you are.

Your office staff can also be the cause of a misunderstanding. The following examples illustrate genuine obstacles to obtaining health care for sexual minorities: The odd look from your receptionist, the nurse who does not understand the need to have a chaperone when examining a female-to-male transsexual, the medical assistant who shudders when seeing nipple rings, and the bookkeeper who refuses to explain a charge on the bill to the patient's significant other. All these can represent genuine obstacles to obtaining health care for the sexual minority patient.

The somewhat unfriendly form or staff can all lead to a hostile or fearful patient. It is probably a good idea to review your patient materials to make sure they are not inadvertently offensive. A frank discussion with your office staff, letting them know that you welcome sexual minority patients into your practice and will not tolerate any disrespect, can also be useful. Be especially aware of the staff member who is tolerant of most sexual minorities, but frightened or upset by a particular sexual lifestyle or behavior; perhaps some education on your part can help allay this person's qualms.

Your own first impression

A physician who is not knowledgeable or respectful about sexual minority practices often reveals that ignorance in the initial history and physical. Consider some more informed ways of asking questions:

Rather than ask Amarital status?"

Ask, "Are you single, married, divorced, separated, or partnered?" The next question is "With whom do you live?"

Rather than "What form of birth control do you use?

Ask, "Do you use birth control?" If the patient says yes, then ask, "What methods do you use?" If the patient says no, then ask, "Do you need birth control?" (If you ask the "need" question first, you will overlook the patient who is relying on the rhythm method.)

Rather than "Do you have any sexual problems?

Ask, "Do you have any sexual concerns?" Then follow up with more detailed questions: General questions alone will not uncover sexual dysfunctions. You have to ask about each specific dysfunction: For example, do you have difficulty having an orgasm, getting an erection, maintaining an erection, experience pain during sex, having an orgasm too soon, lubricate enough or long enough, and do you desire sex? Also, the phrase Asexual concerns" allows the patient to bring up concerns other than dysfunctions.

Rather than "With how many partners do you have sex?"

Ask, "Are you currently having sex with anyone?" If the patient says "no," you can ask "Is that a problem for you?" If the patient says "yes," you can ask, "Do you have more than one partner?"

Rather than "Who beat you up?"

Ask, "how did you get those marks/bruises/welts?"

Rather than "What is your sexual orientation?"

Ask, "Do you have sex with men, women or both?"

Finish the sex oriented part of the interview with, "Do you engage in any sexual activities about which you have health questions?"
 

Respecting your patients' identity and relationships.

It seems only courteous to refer to patients as they request. Nevertheless, it can be difficult to remember to refer to your budding, but balding, male-to-female (MTF) transsexual patient as "she" - to write "Frank" on the prescription, but call her as "Francesca." It can be hard to remember to do a Pap smear on Dick, your female-to-male (FTM) transgendered patient.

It is respectful to include the patient's significant other in major decisions, if that is the patient's desire and despite the relationship's legal status. Sometimes it is difficult to ferret out the relationships that are important to your patient. Your patient may have a wife and a master, or two significant others. It is appropriate and desirable to ask the patient who they would like present.

Dealing with the mistrustful patient.

Many sexual minority patients mistrust traditional medicine. Some of this attitude is understandable. Many alternative sexual behaviors are also psychiatric diagnoses, and in some cases are illegal; many patients have had less than pleasant interactions with non-accepting physicians. Reliance on alternative medicine, folk remedies and the avoidance of traditional medicine are common. Sexual minority patients tend not to attend to health care maintenance or even simple problems. So when they finally seek medical care, there can be serious medical concerns.

For similar reasons, many sexual minority patients also mistrust mental health professionals - so a suggestion that your patient see a psychiatrist or psychotherapist may be greeted with skepticism or hostility, particularly if the patient believes such therapy is an attempt to "cure" the patient's sexual behavior. It goes without saying that consensual and satisfying sexual behaviors among adults, which do not interfere with the patient's functioning, do not need curing. Nevertheless, depression, personality disorders, stress and other psychiatric problems are at least as likely among sexual minorities as in the general population. Due to the stresses of living a non-traditional lifestyle, some emotional difficulties may be more common. Illicit drug fads within (and outside) the various sexual minority communities also may lead to psychiatric and medical problems. Sensitive physicians are able to assure their patients that they are recommending mental health treatment because of the psychiatric problem and not because of the sexual behavior.

Sexual minority patients are concerned, often with cause, that health care providers will pathologize them because of any of their sexual identities or behaviors. You will have better success with these patients if you can assure them truthfully that you do not consider their sexuality to be, in and of itself, a problem.
 

The following glossary is meant to help health care practitioners understand their patients' sexual language. It is not a complete list and not everyone will agree with these definitions, but it is a start. An accepting attitude and honest curiosity will take you a long way. Nevertheless, heed the following warnings:

• Do not use these terms yourself; it is very easy to make a faux pas. Many of these terms have different meanings and pejorative implications when used by someone outside the patient's sexual community; you will be misunderstood!

• Even though these terms have pejorative meanings when used by "outsiders," they are not considered insulting when the patient uses them to self-describe or to describe friends or lovers.

• Do not assume that sexual activities are limited by one's stated sexual identification.

• The definitions of these terms are seriously debated within the sexual minority communities. These definitions are approximate and they do change over time.

Sexual minorities (everything but the traditionally heterosexual) call themselves or their activities queer, perv, pervert, kink, fetish, leather or leathersex. Those who are not sexual minorities are called vanilla or straight; vanilla is also used to describe non-kink sexual activities. To be squicked is to be upset or disgusted by a given behavior.

Someone who is coming out (exploring the activity or beginning to accept the identity) is called a novice or newbie. An attractive partner is cute or hot; hot is also used to describe a particularly exciting interaction. Someone who loves sex (orgasm-seeking behavior) or a specific sexual activity is called a slut. Sometimes there is a specific type of sex that is desired, e.g., pain slut, fuck slut,and anal slut.

So many synonyms exist for male and female masturbation, genitals, and breasts, that it is impossible to list all of them here. Most are in relatively common use outside the sexual minority communities. It is worth noting again, that many terms - for example, the word cunt - do not carry the pejorative implications in these communities that they do in the outside world.

If you are not used to this sort of language, it can be difficult not to react negatively when you hear words you have always been taught are insulting or obscene. Nevertheless, the patient may not know or understand medical or polite jargon.

People who eroticize physical and/or psychological pain (sometimes called intensity or erotic intensity) are called players and are into S/M (a.k.a. BDSM, sadomasochism, dominance and submission or D/S, leather, and bondage and discipline or B/D). Some people attempt to live this as a lifestyle, 24/7 (24 hours a day, 7 days a week) or TPE (total power exchange). Slave contracts codify the rights and obligations of each partner in the relationship; although these contracts have no legal status, they often carry significant moral weight. Other players only do S/M during sexual interactions; they do EPE(erotic power exchange) or keep it in the bedroom. Players usually describe their activities as SSC (safe, sane and consensual). A play party is a social gathering where S/M activities take place; the party space (venue) usually has equipment (large devices to which a partner can be secured). The players usually bring their own toys (handcuffs, whips, canes, etc.).

Toys are typically designed to provide sensory stimulation with minimum physical damage, but they can be misused. Most cities have one or more stores or organizations that teach safe use of these toys. There are also books and magazines available containing such information.

Mixed play or cross-orientation play implies an S/M interaction between people who would not usually have sex together (a gay man with a lesbian, for example). S/M partners engage in negotiation, the process of agreeing what will constitute the specifics of the S/M scene (interaction). They decide upon a safeword (a word or gesture that will stop the scene) and mutually define the limits (activities not to be included in the scene).

Players who take the active role are called dom, domme, top, master, mistress, and sadist. Players who take the passive role are called submissive, sub, subbie, bottom, masochist, boy or girl, and slave. (In some S/M interactions, it may not be immediately obvious which partner identifies as the active partner and which as the receptive partner). Switches can take either role. Within the S/M community, there is often intense debate concerning the distinctions among these terms; statements like "I am a masochist, I will be submissive if my partner enjoys it, but I am no one's slave" are not uncommon.

Whipping, flogging, caning, spanking are common S/M activities. Flogging involves an instrument with several strands of leather or other material to strike one's partner. A single-tail is a braided implement that tapers to a narrow end. The most common place to strike is the buttocks, but thighs, shoulders, and genitals are also common. Marking (leaving bruises, welts, or generalized redness) is common, but not mandatory. Some individuals especially enjoy play involving a specific area of the body, e.g., tit torture, CBT (cock and ball torture), and cunt torture. Edge play (activities that tend to squick people and are more dangerous) include blood play (shallow piercings or cuts that draw small amounts of blood), knife play (using a knife to scratch or cut, or to threaten), electricity(using devices such as TENS units to deliver shocks), and breath play or control (strangulation and suffocation).

These activities are not inherently abusive, criminal or self-destructive. They typically are loving, intimate and well thought out in terms of safety. A standard criterion for S/M play is that it should not cause damage requiring professional intervention to heal (e.g. broken bones, deep lacerations, etc.). However, even careful players sometimes have accidents. It can be useful to compare S/M play to contact sports (football) or high-risk activities (mountain climbing). Injuries do happen in these activities, some are accidental and some indicate that the participant needs more safety training.

Men interested in bears (big, barrel-chested and usually bearded men) are called cubs. Men attracted to men with large penises are called size queens. Daddy and boy imply an S/M relationship; women can use the same terms.

Women who are interested in sex with other women are lesbians or dykes. High femme or lipstick lesbians are women who appear stereotypically feminine (lipstick, make-up, high heels, frilly clothes, etc.). Femme women may also have a decidedly feminine appearance, but not to the extreme. Soft butch women have a more androgynous appearance. Stone butch women tend to be masculine in appearance and may dislike any vaginal penetration themselves. It is common to see a femme woman partnered with a butch, but other pairings are not unusual. These roles may not be all encompassing, it has been said "Butch in the streets, femme between the sheets."

It can be tempting to try to impose the structures of typical heterosexual relationships on same-sex pairings, looking for the "man" and the "woman." While some same-sex couples identify with this paradigm, many do not, and will be extremely offended if you make assumptions regarding their roles.

Bisexuals or bi's are sexually attracted to both men and women. There are political forces that impel people to either embrace or deny the term bisexual; as one woman told me, "If gay men can have sex with women, why can't lesbians have sex with men."

Many people engage in sexual behavior with both men and women without identifying as bisexuals. Additionally, do not assume that bisexuals are always non-monogamous; bisexuality is a matter of identity and attraction, not necessarily of behavior. Safer sex and birth control counseling needs to be inclusive.

Men who like "lesbians" are called dyke daddies, but sometimes this term is used instead to mean butches and transgendered women interested in daddy/boy play. Heterosexual women who like gay men are called fag hags or fruit flies, but these terms do not usually imply sexual activity. Some lesbians interact erotically with gay men and/or in gay male environments.

Many sexual minority members like to blur the boundaries of gender with pronoun confusion. You may hear someone refer to a butch as "he" or an effeminate man as "she."

A permanent or semi-permanent marking is called a body mod (modification), and is attained by tattooing (tats), cuttings (a design superficially or deeply cut into the skin by a knife or scalpel), piercings (placement of metal bars or rings through the flesh). Burns or burning involve using intense heat - matches, cigars, sticks of incense - for sensation only, without attempting to create a design; they are usually thought to be temporary (healing in a matter of weeks), but can be permanent. Branding is the use of heat to make a permanent mark or design. Piercings have specific names for the different locations; some of the most common include Prince Albert or PA (though the frenulum area of the glans out the urethra), guiche (perineum) and triangle (above the clitoris). Some people like the act of piercing and do needle play or play piercings, which are removed at the end of the scene.

Body modifications typically heal themselves within a matter of weeks or months without medical intervention. Many patients, if they encounter trouble with a body modification, will turn to the body modification artist for counsel rather than seek medical advice. If the artist's advice doesn't work, they will come to you - typically with a serious infection. If you treat many members of sexual minorities, it might be worthwhile to learn more about body modifications and their ramifications, and perhaps to form affiliations with some of your local body modification studios.

A relatively common activity for both men and women is handballing or fisting, placement of a hand in the partner's anus or vagina. After the hand is inserted, it is curled into a loose fist, hence the name. Oral-anal contact is called rimming. A butt plug is a sex toy for insertion into the rectum. A strap-on is a dildo (artificial phallus), worn in a harness that allows one to engage in coitus with one's partner despite anatomy or physiology. An individual who enjoys anal coitus (butt fucking or pumping the poop shoot) is called a back door betty or an anal slut. Felching is the act of sucking one's cum (semen) out of a partner's rectum, and sometimes sharing it orally with the original recipient.

Not all the most "shocking" sexual activities are the most dangerous, and vice versa. If your patient trusts you enough to tell of engaging in some of these behaviors, a nonjudgmental consultation on the possible health ramifications (HIV, Hepatitis, other STDs, as well as physical injury to the rectum or colon) of what s/he is doing. Some of these activities are not particularly risky from a health standpoint, and many of the risks that do exist can be easily mitigated with latex barriers and other prophylactic strategies.

When your partner is aware that you have or could have more than one partner, you have an open relationship. Many people in open relationships have an SO (significant other) or primary partner, and the other relationships are called secondary or fuck buddies. Those who are open to more than one primary relationship are called poly or polyamorous. Individuals who are straightforward and honest about their activities are called ethical sluts. Fluid-bonded describes a relationship agreement not to use safer sex precautions among those partners, but are mandatory with other partners. Swingers are male-female couples who seek other couples, but will occasionally allow a single to join them. The gay male version of swinging occurs at the baths or a bathhouse. Venues designed for swinging or group sex are also called sex clubs or sex parties; they usually have a group room for group sex. Group sex involves orgasm-seeking behavior by three or more individuals at the same time. Female-only sex parties also exist but are less common.

Non-monogamous relationships can be as healthy as any other relationship style. People in ethically non-monogamous relationships can and do maintain long-term commitments and raise happy families. The kinds of behaviors encountered among the nonconsensually non-monogamous (lying, deception, etc.) are not integral to the phenomena.

An exhibitionist is someone who enjoys displaying him or herself nude, in sexy dress, or engaging in sexual behavior in front of others; a voyeur is someone who enjoys watching a sexual display. Both exhibitionism and voyeurism may be consensual or nonconsensual. The nonconsensual versions are illegal.

Someone can be turned on by dressing in specific garments (drag), which include latex, PVC (polyvinyl chloride), leather, and corsets. For some people, their outfit defines the fantasy that they are playing out. For the TV or transvestite, the pony girl/boy (someone who dresses up as a pony to pull a wagon or carry a rider), the furrysex aficionado (someone who role-plays being an animal having sex), or the infantilist (someone who role-plays being an infant), dressing up may be integral to the experience. For others it is a more comfortable way to present themselves to the world; this is not drag, but implies a desired life role. It is the difference between dressing to enhance sexual arousal and how one wishes to be perceived.

A fetish is an erotic attraction to an inanimate object, or to a particular aspect of a human partner; some sexologists distinguish between a fetish (erotic attraction to an inanimate object) and a partialism (an erotic attraction to a body part). Common fetishes include shoes, cigars or cigarettes, and materials such as rubber or leather. Common partialisms are feet, breasts, buttocks, hair, and body fluids such as urine, blood or sweat. Fetishwear are costumes designed to provoke a fetishistic response, such as corsets, boots and leather motorcycle gear.

Many kinds of non-traditional erotic behaviors do not include conventional genital sexuality. Do not assume that your patient's involvement in fetishism, S/M, crossdressing or other erotic activities necessarily means that genital stimulation occurs while involved in these activities.

Cross-dresser is a generic term for all those who dress in the clothes of the opposite sex. Gender-fuck describes a person or activity that involves someone dressing with stereotypic aspects of both men and women at the same time (e.g., having a full beard while wearing a dress). A female impersonator or gender illusionist dresses as a woman as part of a theatrical performance. A drag queen is a gay man who dresses and acts in a stereotypically feminine style, sometimes to an outrageous and humorous extreme. A drag king is a lesbian who dresses and acts in a stereotypically masculine style.

People who dress in the clothes of the other sex come in a variety of types: Transsexuals(TS) are people who feel that they are members of the other sex trapped in the wrong body. They usually desire hormonal treatment and gender reassignment surgery (also called sex reassignment surgery). They are often divided into MTF (male to female) or FTM (female to male) and pre-op and post-op groupings as appropriate. Transsexuals who do not intend to have surgery are called non-op. Transgendered (TG) people are those who choose not to think of themselves as one gender or the other; they may appear androgynous, or may appear as one gender at some times and another at others. Some TG people are TS's who do not desire surgery. Dressing in the clothes of the opposite sex, sexually arouses transvestites (TV). Most, but not all, people in this category are genetic men (although this question is debated). A chick with a dick is a TG genetic male, usually with the implication that her penis works and she will use it during sex; it can also mean a genetic woman with a strap-on.

Intersex or IS describes individuals with one of several biologic (genetic, physiological or anatomical) conditions that produces physical aspects of both men and women. IS individuals may or may not consider gender an issue for them.

All these categories are extremely fluid, and people who considers themselves transgendered may dress the same, present the same way, and have the same medical issues as those who consider themselves to be cross-dressers or a transsexuals.

Sex workers are those who earn money for providing sexual or erotic services. People who provide conventional sexual services are called prostitutes, hookers, hustlers, whores, streetwalkers or callgirls. Professional dominants, pro-dommes or dominatrices provide S/M scenes in exchange for money; male professional dominants, and pro-subs or professional submissives, do exist but are rarer. Phone sex workers, strippers and exotic dancers, and professional escorts are also usually considered sex workers.

A sex worker may or may not provide conventional sexual activities such as intercourse and oral sex, and may or may not use safer sex strategies. Most sex workers are at some degree of physical risk (assault, robbery, rape, homicide) and legal risk (arrest for prostitution and related crimes).

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