CASE 12

Denise Smith

A 41-year-old Caucasian woman with asthma

John Paul Sánchez MD, MPH,1 Nelson Felix Sánchez, MD,2 and Ana Núñez, MD3

Educational Objectives

TACCT Domains: 1, 2, 4, 6

Case Summary, Questions and Answers

Denise Smith is a 41-year-old Caucasian woman who has lived in New York City her entire life. For the past 10 years she has shared an apartment with another woman who has two children, ages 11 and 13 years. She works as a security guard at a local school but is also a well-known party promoter and event planner in her community. Until her recent employment as a security guard, she did not have health insurance and her only contact with the health care system in the past 5 years consisted of four visits to the Emergency Department (ED) for shortness of breath and wheezing.

Over the past 5 days she has had a viral syndrome, accompanied by a nonproductive cough and worsening shortness of breath. She visits the local health department clinic (her last visit was 7 years ago) for a refill of her asthma inhaler.

As she enters the waiting room, she draws stares from other patients and staff. She has a very short, dark haircut and is wearing black sunglasses, black slacks, a white button-down shirt, and baggy blazer. She walks up to the front desk to check in for her appointment and the clerk responds, “Sir, please write your name down and you'll be called shortly.” A half hour later, a nurse calls out, “Denise Smith, please come to the door.” On coming to the door, the nurse says to Ms. Smith, “Sir, I was calling for your wife.” There are several snickers from other patients in the waiting room.

Ms. Smith pushes open the door and walks through. She refuses to allow the nurse to take any vitals and asks to see the doctor immediately. The nurse hands the patient chart to the doctor and informs him that the patient is in the room. On entering the room, the doctor asks, “Sir, has your wife stepped out to the bathroom?” Disgusted by the confusion once again, Ms. Smith angrily responds, “No, I'm Denise. Doesn't anyone know who I am? Look, I've been waiting here for an hour and all I need is a refill for my asthma pump. Can't you just do that for me?”

1 What are the issues surrounding the misidentification of this patient?

This case illustrates the tendency to interpret human identification from the context of “what are you?” rather than “who are you?” Ms. Smith's interaction also affords an opportunity to examine the multiple influences of gender and identity on her health status. First, the front desk staff did not notice her name as she signed in. Second, the staff rebuked her attempt to enter the clinic when her name was called. She then feels insulted as she enters the examination room; most people, when mistaken for a gender other than their own, do feel insulted. Ironically, most lesbian patients are invisible to their physician and have been named the “invisible minority.” They appear like any other women in the practice and their reticence to divulge “personal information” is misread as shyness, lack of trust, or merely being too busy to answer the questions.

Why did the staff misidentify her? Many people are raised to expect sexual stereotypes. For example, “girls wear pink” and “boys wear blue,” and only boys have shaved heads and only girls have pierced ears. Androgynistic (not having characteristics, dress, appearance, or behavior that are distinguishably masculine or feminine) appearing people may confuse service professionals, such as front desk, clinic staff, or physicians. The majority of people in the U.S. assume that all people are heterosexual. The reflex questions, “Are you married (implied being to a man)?” and “What is your husband's name? provide two common examples of presumed heterosexism. As in most errors in medicine, cutting corners and working rapidly can also result in adverse outcomes.

From a communication perspective, adopting an approach of asking, rather than assuming, is essential to avoiding unintentional insults or conveying an inclusive office setting for all patients. In this case, the front desk clerk, the nurse, and the doctor mistakenly identified Ms. Smith as a man rather than a woman, based on her attire. Aside from appearance, paying attention to how a patient introduces herself (i.e., Ms. Denise Smith), what gender is checked off on the intake or registration form, or what name appears on the insurance card helps to better clarify how the patient wishes to be identified. The health professionals could have rephrased their questions to be more culturally sensitive. The front desk clerk could have simply stated, “Please write your name down.” The nurse could have stated, “Hi, I'm Nurse Williams. And you are?” And the doctor could have stated, “Hi, I'm Dr. Jones. Are you Denise Smith?”

2 What are the implications of misidentification on development of rapport with a patient and a perceived sense of safety in a health care setting?

It is unlikely that a patient will feel safe if he or she is in an environment where “they don't even know who you are.” There are ample messages by the media of patient misidentification, error, and harm as a result of medical misadventures. It is easy to forget that, in the environment where physicians feel comfortable with the routines and setting, most patients are still extraordinarily anxious even when they are healthy, much less if they are sick and feel ill.

Ms. Smith, in this case, is a woman who is a lesbian, but she could also have been a heterosexual artist or an avid sports enthusiast. In medicine, we often use our eyes to decide and define what (and who) we see. This proclivity fails us, more often than not. We need to ask, facilitate the discussion, and hear who the person defines herself as, rather than making judgments based on an impression. Asking rather than assuming is a safe habit to prevent erroneous misattribution.

3 How should the office staff have responded to rectify this problem?

The staff members should have apologized to Ms. Smith and responded by saying, “I am so sorry, please come in. How are you today?” If they did not apologize, the issue should have been shared with the physician so that he could convey his apology for how she was treated upon arriving to the clinic.

The physician should have said “Oh, I'm so sorry; Ms. Smith, how are you? What brings you here today?” If the staff member had shared with the physician her story as in, “we called her 'a guy' by accident and she's only here for a refill of her inhaler and in a rush,” he might have had advanced warning of the patient's perspectives and concerns. Working as a team and treating staff members respectfully, as well as soliciting their input on “what is going on” with a patient, are essential skills in working together and delivering unified and effective health care.

To promote an inclusive medical environment there needs to be intentional actions and trainings to raise awareness, even beyond sex role stereotypes and bias. When a lesbian patient fills out a form that has her choose married, divorced, or single, what does she select if she and her partner of 11 years can't marry in the state they live in? Does she check married and then get asked, “What does your husband do?” or does she select single and have no information about her support system or life? Intentional actions and training need to occur because good intentions are insufficient to raise insight about heterosexist assumptions as well as homophobia. Presumed heterosexism means that a person assumes everyone is heterosexual. Therefore, all women are asked if they have a boyfriend or husband; all men are asked if they have a girlfriend or a wife. By limiting options, a physician can put a patient into a position of not being truthful (telling you what you want to hear.) This is especially true if there is no preexisting relationship. Will the physician judge the patient or treat her poorly if she shares that she is a lesbian? The literature has ample examples of patients being treated harshly or poorly as a result of homophobia, so patients are not unfounded in their concern.

Because homophobia and presumed heterosexism are prevalent in mainstream culture, training sessions to discuss these issues with staff should occur and be facilitated effectively. Unless staff and clinician trainings occur, an open discussion about gay and lesbian patients cannot occur in a productive fashion. By realizing the life experience of lesbian patients and developing an empathetic perspective, all health professionals can contribute to decreasing health disparities in this population of patients.

4 What is important to understand about Ms. Smith's community?

In evaluating the sexual health of all patients, clinicians need to understand key issues about sexual orientation. Sexual orientation runs across a continuum and has three components: attraction, cognition, and behavior. Attraction or desire describes a patient's sexual affinity. Cognition is how they choose to define themselves, for example straight, bisexual, gay, or lesbian. Behavior, as it sounds, is what a patient does or doesn't do. Patients may choose to be sexually active with another person or themselves or be celibate. These three areas often cause confusion in understanding sexual behavior because they do not necessarily track together.

A woman may have sex with a man, yet identify herself as a lesbian. A woman may not have sex at all and identify herself as bisexual. A woman may be in a committed relationship with another woman but vehemently refute the label of “gay.” Our patients may or may not share information with us about whom they are attracted to. They can define themselves as they see themselves: their identity. Hopefully, we can create a safe space in the medical setting to enable patients to share what they do and with whom, so that we can best serve in helping them understand their health risks.

Gay culture, like all learned behavior and cultures, has social norms, expectations, traditions, values, language (both verbal and nonverbal), and behaviors. The degree of acculturation varies from person to person, just as the role of any cultural influence is balanced by individual influence and may change over time. To make the cultural implication even more challenging, the role of being gay in a person's identity varies with age, geography, religion, ethnicity, socioeconomic status, and education. So, the role of gay culture on a patient may be one of many influences on the individual patient in front of you.

Lesbians and Health Disparities

A Lesbian is a woman who forms a primary intimate relationship with another woman and who is sexually oriented to the same sex. Estimates of the number of lesbians in the U.S. vary, but could be from 2.2 to 11.8 million people. This data range estimate applies Lauman's estimate of women who identify as lesbians (1.4%), Kinsey's' data (5-6%) and Michael's data (7.5%) on women who report same gender desire on current population (October 2007) of 153.6 million women in the U.S.

But beyond statistics, many people do not know that lesbians as a group are as diverse as any other group in the U.S. They are of all socioeconomic classes and of every ethnicity. They live in every state in the U.S. They are childless and they have children. Based on the literature, about two-thirds of them have or have had sexual intercourse with men (which influences sexual health risks.) Additionally, there are gay and lesbian staff, health professionals, and physicians who may or may not feel safe nor supported where they work.

Barriers to access health care among lesbians include: stress effects of homophobia, obesity, smoking, cardiovascular, mental health, and substance abuse issues, and cancer. Lesbian women are a difficult group to research regarding their health habits, as discrimination in the workplace as well as personal safety are issues for sexual minorities. Much of the literature about lesbian women has been collected from small numbers or from convenience samples – for example, groups of women attending a social event. The health habits of individuals who frequent social events are likely to be different than those women who do not participate in these activities or whose lives center around the raising of children. Consequently, future studies on the health of lesbians need to be designed to appropriately sample this population of women.

The doctor explains to Ms. Smith that, before he can give her any medication, he must conduct a history and physical examination. Ms. Smith agrees but urges the doctor to be quick because she's promoting an event later that evening. Her past medical history consists only of asthma, with increasing episodes of wheezing in the past 3 months, which worsen when she’s chasing after kids at school and after her events in the evening. She has had the same albuterol inhaler for the past 6 months, which over the last several days she has used six to eight times each day. Over the past week, she has had a “cold” that she believes is the main cause of her worsening shortness of breath. She has a nonproductive cough but feels like there is something in her lungs. She smokes about 10 cigarettes a day, more when she’s stressed, which has been the case over the past 3 months, but much less than about 5 years ago when she was smoking 1.5 packs per day. When asked if she has ever tried to quit, she avoids the question and replies, “Look I’m not here to be judged. Why does it matter if I’ve ever quit or how much I smoke or, for that matter, what else I do? Listen, what I do is my business. This is why I stopped coming to the doctor; all of these personal questions. The last doctor made all of these suggestions to me and my partner on how to quit and none worked. Great, now I feel more short of breath than before.”

She reaches for the inhaler and takes a puff. The doctor asks to see the inhaler and discovers that it is empty. Pressed by her urgency to leave, the doctor ends the history and proceeds to the physical examination. He limits his examination to the lungs in which he hears scattered wheezing and good air entry.

“Okay, Ms. Smith, we’re going to give you an asthma treatment and then I’ll come back and re-assess you.”

5 Why does Ms. Smith feel like she is being “judged?”

This comment may reflect anger, frustration, and hurt on a number of levels. She may be expressing residual anger over the initial encounter with the clerk, nurse, and physician. This anger was further compounded by the fact that the staff did not acknowledge their inappropriate comments either through an apology or by asking Ms. Smith her preferred terms of self-identity. This, in turn, may have led Ms. Smith to project a more “aggressive” or “hostile” demeanor that hampers effective doctor–patient communication. Ms. Smith may also be expressing frustration over a sense that, rather than addressing her asthma, the reason she came to the clinic, the doctor is focused on her smoking, a habit she has been unable to give up despite efforts to do so. In addition her comments may reflect life experiences, whether real or perceived, of bias and mistreatment in the health care system or in the wider society.

If a patient feels “judged” (i.e. dismissed, discounted, disrespected), the effectiveness of the doctor–patient interaction is jeopardized. A patient may be less willing to provide an honest or complete history of illnesses, behaviors, or existing support networks. A patient may be less inclined to undergo a more extensive or “invasive” physical examination, such as a pelvic examination, especially if they do not plan to continue care with that provider. The development and implementation of a feasible and effective treatment plan requires that the patient and physician can communicate openly about the patient's desired health outcomes, perceived obstacles, and services needed to achieve these outcomes. Developing and maintaining a strong, supportive, and comfortable relationship with patients can facilitate success throughout the doctor–patient encounter.

Thirty minutes later, the doctor returns and, on reexamination of Ms. Smiths’ lungs, discovers improved air entry and no wheezing. The doctor informs Ms. Smith that her asthma was probably exacerbated by her recent cold and continued cigarette smoking. He writes prescriptions for an albuterol inhaler and 5-day course of steroids and instructs her how to assess when the inhaler is empty.

“Ms. Smith, I realize you have been unhappy with the care you have received today, and I apologize if I or my staff made you uncomfortable. If you can spare the time, I would just like to talk with you a little more about your smoking since I think it’s affecting your asthma.”

Ms. Smith replies, “Doctor I hear what you’re saying, but I’m sure it was the cold not my smoking. I smoke every day, but my asthma only really gets bad when I also have a cold or I’m stressed. I can try and cut down, but I’m not ready to quit. Cigarettes help me relax which I need right now. I’m a party promoter, so I smoke, especially when I’m out with my girlfriends. It’s a part of the scene.” She explains that many of the women who attend her events at clubs and restaurants smoke.

The doctor asks, “Tell me about some of the important people in your life. I see you're wearing a ring on your wedding finger. Do you currently have a partner?”

“I have a wife.”

“And do you identify with the term lesbian or another term?”

“Lesbian.”

“Does your wife smoke?” “Yeah. We try not to smoke too much in the house because of our kids. Our 11 year old has asthma, and the cigarette smoke makes him cough.”

Smoking Influences and Quitting Rates: Women vs. Men

In the U.S., 22% of women smoke, and there continues to be increased rates of smoking among teenage females compared with their male counterparts. The prevalence of smoking among women is positively associated with younger age, lower income, lower educational level, a disadvantaged neighborhood environment, and certain racial/ethnic groups.

Gender parity in smoking has resulted in lung cancer now being the leading cause of cancer-related deaths in women, surpassing even breast cancer.

Most smokers will require multiple attempts at quitting smoking (on average 7 to 9 sincere attempts) before they can quit, and women are no exception. Women, more often than men, however, use smoking as a weight control measure and therefore have more difficulty quitting since most ex-smokers gain weight after ceasing to smoke. Women, as compared with men, have more societal pressure about their appearance and this plays a role in their smoking-cessation challenges.

Different than men, women have much higher rates of depression with quitting. This is one of the reasons that some modalities that help mood and smoking cessation may be more useful in women. Lastly, women often benefit from culturally appropriate, social support settings to enable quitting.

6 What are some of the challenges that may make it more difficult for Ms. Smith, as a lesbian woman, to quit smoking?

Smoking rate estimates vary among lesbians from 11% to 50%. Significantly, there is evidence that lesbian women may have increased smoking rates as they age, which differs from heterosexual women, who have lower rates with aging. Lesbians have been shown to have a higher rate of anxiety and depression due to stigmatization and homophobia. Cigarette smoking may be one strategy that lesbians employ to deal with the burdens of stress and homophobia associated with their sexual orientation. Anxiety and depression can lead to isolating behaviors that further decrease social resources, and the desire to smoke often increases with anxiety and depression. It is also important to realize that some tobacco companies have demonstrated public support for lesbian, gay, bisexual, and transsexual (LGBT) organizations through financial donations and visibility at LGBT events. This creates, in some LGBT people, a sense of loyalty to certain brands of cigarettes. By smoking these brands, LGBT smokers believe they are supporting a company that uses advertising intended to attract LGBT consumers. Lastly, there is a paucity of research that has targeted lesbians to validate smoking cessation approaches that would be effective in this group of women.

Despite numerous adverse factors, Ms. Smith has attempted to quit smoking a number of times before. Ms. Smith has also successfully cut down from one to a half a pack of cigarettes per day. Her wife has also cut down, and they have seen a significant amount of monetary savings. However, despite seven prior attempts, she has been unable to quit. She has tried the nicotine patch, nicotine gum, and hypnosis. She even attended a smoking cessation support group with her wife but felt the group was not accepting of their lifestyle. They know that smoking does affect the health of their children and their health, but they are unable to quit.

7 What can Ms. Smith do and how can the physicians help motivate her behavior change?

Assess willingness to quit. The physician needs to first determine whether Ms. Smith is, in fact, ready to quit. The literature is quite clear that, if the patient is not truly ready to make a change, sustained smoking cessation is unlikely and efforts at this time will result in patient frustration and pessimism regarding success in subsequent attempts to give up cigarettes.

Emphasize the benefits of quitting smoking. For Ms. Smith, these might include improved health and better control of her asthma; saving money (which actually can be strong a motivation for quitting); and avoiding the detrimental effects of second-hand smoke on her children, such as ear or respiratory tract infections. “Scaring” patients into quitting by simply emphasizing that smoking will kill them rarely motivates patients for long-lasting change.

Review past attempts at quitting. Her physician should acknowledge and affirm her past efforts to give up smoking and then explore what worked, even if only briefly when she previously tried to quit, and then what propelled her to “light up” again. This may be useful in highlighting her personal awareness of a more effective quitting plan.

Enlist support of loved ones. A potentially very useful strategy is to identify family members and friends who can be recruited as allies in her effort to give up cigarettes. Given that Ms. Smith's partner also smokes, it may be helpful to negotiate with her partner about setting a mutual quit day, as it is extraordinarily difficult among any couple to have one person quit while the other continues to smoke.

Develop a plan jointly with the patient. The physician can provide medical therapy for nicotine replacement and mood disturbances, referral to support groups or smoking cessation programs, including LGBT-friendly programs, and advice for dealing with withdrawal symptoms and avoiding weight gain. In developing a plan with Ms. Smith, it is essential to ask her what she can do as first steps, rather than providing numerous options of what she should do. The plan should include follow-up with the physician.

References: Case 12

Aaron D.J. Behavioral risk factors for disease and preventive health practices among lesbians. Am J Public Health 2001;91:972–5.

Bergen A.W. Cigarette smoking. J Natl Cancer Inst 1999;1365–75.

Census Data Facts for Features. CB08-FF.03 Jan. 2, 2008. Available at: http://www.census.gov.

Dibble S.L. Risk factors for ovarian cancer: lesbian and heterosexual women. Oncol Nurs Forum 2002;29:E1–7.

Dibble S., Roberts S., Nussey B. Comparing breast cancer risk between lesbians and their heterosexual sisters. Women's Health Issues 2004;14(2):60–8. Lesbian Health Research Center: USCF. Available at: http://www.lesbianhealthinfo.org

Doolan D. Efficacy of smoking cessation intervention among special populations. Review of the literature from 2000 to 2005. Nurs Res 2006; 55(4S):S29–37.

Fagerstrom K. The epidemiology of smoking: health consequences and benefits of cessation. Drugs 2002;62:1–9 (suppl 2).

Fiore M.C. US public health service clinical practice guideline: treating tobacco use and dependence. Respir Care 2000;45(10):1200–62.

Gay and Lesbian Medical Association and LGBT Health Experts. Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual and Transgender (LGBT) Health. Gay and Lesbian Medical Association, San Francisco, 2001.

Kaiser Permanente National Diversity Council and the Kaiser Permanente National Diversity Department. A Provider's Handbook on Culturally Competent Care: Lesbian, Gay, Bisexual, and Transgender Populations. Oakland, 2000.

Kinsey A.C., Pomeroy W.B., Martin, C.E., Gebhard P. Sexual Behavior in the Human Female. W.B. Saunders, Philadelphia, 1953.

Laumann E.O., Gagnon J.H., Michael R.T., Michaels S. The Social Organization of Sexuality: Sexual Practices in the United States. University of Chicago Press, Chicago, 1994.

Lehmann J.B. Development and health care needs of lesbians. J Women's Health 1998;7:379–87.

Michaels S. The prevalence of homosexuality in the United States. In: Cabaj R.P. c12_image001.jpg Stein T.S., eds. Textbook of Homosexuality and Mental Health. American Psychiatric Press, Washington DC, 1996, pp 43–63.

Mravcak S.A. Primary care for lesbians and bisexual women. Am Fam Physician 2006;74(2):279–86, 287–8.

Ryan H. Smoking among lesbians, gays, and bisexuals: a review of the literature. Am J Prev Med 2001;21:142–9.

Sanchez J.P. Cigarette smoking and lesbian and bisexual women in the Bronx. J Community Health 2005;30(1):23–37.

Stevens P. An analysis of tobacco industry marketing to lesbian, gay, bisexual, and transgender (LGBT) populations: strategies for mainstream tobacco and prevention. Health Promot Pract 2004;5(3):129S–134S.

Valanis B.G. Sexual orientation and health: comparisons in the women's health initiative sample. Arch Fam Med 2000;9:843.

Women and Smoking: A Report of Surgeon General. United States Public Health Service, Office of the Surgeon General, Washington DC, 2001.

1Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA

2Memorial Sloan-Kettering Cancer Center, New York, NY, USA

3Drexel University College of Medicine, Philadelphia, PA, USA