A young diabetic man sits looking embarrassed and dejected, as he is questioned by another young man about what lay behind his recent admission to A and E , after vomiting and passing out, showing all the signs of ketoacidosis (lack of insulin in the body). The first young man is in his first year at university, and the reasons he gives for suddenly failing to look after himself after he leaves home are typical of people diagnosed with Type One diabetes when they were children:
“You know. I wanted to fit in. Drinking and staying up late. Not eating regularly … Plus I didn’t want people thinking I was a junkie when I inject myself [with insulin]…”
The second young man - a medical student - is sympathetic, “Surely everyone is in the same boat when they start uni? Other students will understand…”
“Yes,” trails off the young patient, looking intensely uncomfortable. The middle aged woman watching from the corner of the room silently urges him to say more but he doesn’t.
The medical student turns to her- and sums up: “A typical case of non compliance in late adolescent Type One diabetics…”
“But there are other reasons for your non compliance, aren’t there?” the middle aged woman says, looking down at the case study details. The young patient doesn’t make eye contact.
“Ok” says the middle aged woman, who is a Communication Skills Teaching Fellow. “David is a young diabetic who also happens to be gay.”
The medical student bristles visibly. “What’s that got to do with it?” he asks. The rest of the group shift in their chairs. Some of them are staring at the floor.
“Well,” the middle aged woman ploughs on. “This is the first time you’ve got away from your over-protective home, isn’t it, David?” She glares at the patient, who isn’t really a patient at all, but a paid role player.
“Mmmm,” he says. The middle aged woman looks pointedly at her notes. “David hasn’t come out to his parents, or indeed anybody - and, as a diabetic, has felt different from everyone else all his life - and is damned if he is going to feel a double outsider – so - he doesn’t come out to his fellow students, but goes off to clubs late at night, drinking and possibly taking drugs”. She knows she’s probably going over the top now- but she feels that she has to make the point. “The fellow student who brings him to A and E doesn’t even know about his sexuality…”
“Are you implying that all gay people drink to excess and take drugs?” the medical student interrupts.
“I don’t touch either, for instance.”
Cries of “No he doesn’t…” and “Aren’t you being homophobic?” come from the rest of the group, eager to support their fellow student, who is confident and popular. The role player nods in agreement- and is clearly relieved that the spotlight has moved to someone else.
“I mean- he’s presenting with Type One Diabetes, not an STD”, the medical student goes on.
The middle aged woman is horrified. She was trying to make a point about LGBTQ mental health and now the group appears to be turning on her for being homophobic! She’s cornered and only has one option: “Speaking as a lesbian myself, it is a mistake to assume that LGBT health concerns are purely confined to sexual health”, she says. The medical student is open mouthed. Probably the rest of the group are too, but she’s not looking at them, or the role player. “You should look at the statistics amongst young LGBTQ people: Much higher rates of smoking, alcohol and drug abuse- all connected with social pressure …”
“Yes- yes. Of course. You’re right.” The medical student says immediately. “And higher rates of depression“
“Self harm…” Relieved, they go on and together they start to enlighten the bewildered group of students who haven’t heard any of these statistics before.
And so started a firm friendship. I was, of course, the middle aged woman- veering into late middle age, even. I might even have been wearing a skirt on that occasion- and, following a civil partnership a few years previously, I wear a ring on my wedding finger. We were all knee deep in assumptions in that teaching room. The students assumed I was heterosexual - if not asexual - and probably vaguely prejudiced against gay people. I assumed that few gay medical students are out (not a totally misplaced assumption, born of 10 years’ experience of teaching there). The gay medical student assumed that consultations about sexual health were the only situations in which it was appropriate to talk about the subtleties of his own experience- although he knew all about the growing research on the ill effects of social pressure and discrimination on LGBTQ mental and physical health. The role player assumed that it was OK to miss out an essential element of his case study information- probably, I suspect, because he was uneasy about it himself. He might even have been told not to bring it up unless asked about it, which wasn’t going to happen, because there were no clear details within the case study which might have led to disclosure. As the tutor, I had to break the conventions of communication skills training to bring the full history out in the open.
The medical student later told me that he and the group spent the whole of their lunch break discussing the issues which emerged from the session- and most of the rest of the day. He and I met up for a coffee( the first of many) and planned how we could tackle the medical school culture further to raise awareness that LGBTQ ill health is not just about sexual health, but should be explored as an equality issue. I introduced him to David Viney at the Birmingham LGBT Centre, and an older gay friend of mine and eventually, we wrote this article for the Med School Student Newspaper: https://bhamqmm.wordpress.com/).
Interestingly, I have never felt the need to be specific about my sexuality in a teaching situation before. If asked, I never disguise the gender of my partner- so it usually emerges anyway if I am in a longer term teaching relationship rather than a small group session with students I’ve never met before, as was the case this time. I broke my usual mode of interaction in this instance- and felt reckless in doing so. But that dynamic moment in an otherwise ordinary teaching encounter led to lots of things in addition to the writing of the article:
1) A resolve as a teacher to develop role player training to address the idea that it is not enough to simply include homosexuality as a feature of the “patient”’s life without considering the social and psychological impact on his/her life and to structure the improvised scenario to provide cues for the medical student who listens carefully.
2) The decision to work with other LGBTQ colleagues in medical school contexts to raise awareness of the depressing statistics around LGBTQ mental health
3) A wealth of conversations with friends and colleagues on the whole question of to “come out or not to come out” in teaching situations, which has led me to reflect on whether the whole incident highlighted, above all, the need for role models. It required both the medical student and myself to come out in order to drive the message home about LGBTQ mental, as opposed to sexual, health. I’m sure that the handful of students in that small group will remember that point. The article in the student newspaper which the session led to will also have an impact. But what is worrying is how many medical students, who are future doctors, are not exposed to that information about a significant health inequality, because of the lack of LGBTQ role models in medical education.
4) And, finally, it led to many many re-tellings of the story on how it felt to be jumped into being honest about my sexuality in a teaching context without a moment’s hesitation. Was my motivation to educate students about LGBTQ mental health- or simply not being able to bear being perceived by students as a middle aged, middle class bigot! You decide….
Visiting Lecturer at Birmingham Medical School
Artistic director, HEARTH - Change Through the Arts
www.thehearthcentre.org.uk
