CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
PHYSICIANS' KNOWLEDGE!, ATTITUDES AND PRACTICES
\\
j
REGARDING HOMOSEXUAL MALES WITH GONORRHEA OR SYPHILIS
A thesis submitted tn partial satisfaction of the
requirements for tbe degree of
Master of Public Health
by
Christine Marie Peterson Maqueira
June, 1979
I
The Thesis of Christine Marie Peterson Maqueira
is Approved;
i
Roberta Madison, Dr. P.H.
Michael Kline, D~
Cornrrdttee Chairperson
California State University, Northridge
ii
,_.
...
:_·;
_:_
To Dad, Peg, Rick and Mike;
To Teri, who supported me
through the worst part;
And to Grace, who loved and
supported me through the rest,
I dedicat.e this Thesis
iii
ACKNOWLEDGEMENT
I wish to thank Anthony Scarcella, M.D., for his
extremely helpful evaluation of this thesis from a medical
standpoint.
Special thanks are expressed to Goteti Krishnamurty, Dr. P.H., who believed in me and couns.elled me
throughout my entire stay at C.S.U.N.
Thank you also to
Glen Frew and Tony Alcocer, Dr. P.H., for caring so much;
and to Michael Kline, Dr. P.H., Waleed Alkhateeb, Dr. P.H.,
and Roberta Madison, Dr. P.H., for continued help, support
and encouragement.
This thesis would not have been possible witho:It
the contribution of the Los Angeles Venereal Disease
Information Council.
I am very grateful for that assis-
tance.
Finally, I wish to express my special thanks and
gratitude to the following people:
Hernan Merino, Loren
Senseman, Marion Harris, Melinda Head, Lauren Boehm, Edd
Henry and the Night Crew in C.C.U., Granada Hills Community Hospital.
iv
TABLE OF CONTENTS
PRELIMINARIES
PAGE
Dedication
iii
Acknowledgment
iv
List of Tables
vii
Abstract
CHAPTER
I.
X
INTRODUCTION
1
Statement of the Problem . • • • . • . • . • . • . . . • • • • •
Purpose of the Study .•.••••.•.•..•.••..•..••
3.
4
The Hypotheses ...•
5
411
•
•
•
•
..
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Limitations of the Study....................
Definition of Terms .•..••••••••..•••..•..••.
Justification for the Study ...•.••.•••••..••
V.D. Educational Programs .••..•••.•.••.
Assumptions regarding V.D. in
2
Homosexuals ..•...•.•.•.•••• ·. . • • • • . . • • • •
9
Gonorrhea and Syphilis in Gay Men ...•..
11
REVIEW OF THE LITERATURE: AN HISTORICAL
PERSPECTIVE . . . . . . . . . . . • . . . . . . . . . . . . . . . .
13
Homosexuality in Medical Literature
Before the 1950's ..• ~····~·~~··········
The Wolfenden Report •....•..•••.••••.•••..•.
The 1960's: a Dilemma for American
Physicians .•..••.••••.••••••..••.••••••
·3
4
5
6
7
8
13
14
15
The Early and Mid-1970's: Sexual Liberalism
in Medical Literature ••..•...•..••.•..•
From 1976 to the Present: an Emphasis
on Aggressive Casefinding ··········~···
19
METHODOLOGY •••.••••••.••••••.••••••
~........
22
The Research Design Plan •.•••.•...•••••••.••
The Design of the Questionnaire •..•.•••.•.••
The Response ···············~ ....•...........
22
26
29
RESULTS AND DISCUSSION ••..•••••••.••••••••••
31
Knowledge, Attitude and Clinical Practice .••
Number of Patients Seen,< ......................
35
40
v
17
TABLE OF CONTENTS (continued)
CHAPTER
PAGE
Identifying the Homosexual Patient •••.••••••
Asking Patients about Homosexual Contacts ••.
Asymptomatic Infection ••••••••••••••••••••••
Three-site Examination and Culturing ••••••••
Treatment of Rectal and Pharyngeal Gonorrhea.
Attitudes Toward Gay Male Patients ••.•••••••
The Importance of Understanding the Gay
Male Life Style • • • v • • • • • • • • • • • • • • • • • • • •
·Medical School Training Regarding
Homosexuality . . . . . . . . . . . . . . . . . . . . . . . . . .
Age of Respondents ••••••••••••••••••••••••••
Sex of Respondents .•••••••••••••••••••••••••
5.
49
51
59
60
71
73
83
88
91
97
CONCLUSIONS AND RECOMMENDATIONS •••••••••••••• 100
Conclusions
. . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .
Recommendations •.•••••••••.•••••••••••...•••
100
103
BIBLIOGRAPHY .••••••••••••••••••••••••••••••••••.••••• 107
APPENDICES ••••• ~ ••.•.••• ·•••••••••••••.•••.•• ·•.•-••.•••• 114
A.
Introductory Letter and Questionnaire
Sent to the Survey Physi~ians ·······~··· 114
B.
List of Significant Chi Square
Results and Correspondi~g Pearson
Correlation Coefficients •.•••••••••••••• 120
vi
LIST OF TABLES
TABLE
PAGE
. . . .. .
. •· .....
. . . . ...
1.
Values for Knowledge Question Responses-
2.
Values for Attitude Question Responses
3.
Values for Practice· Question Responses
4.
Crosstabulation of Attitude by Knowledge
Controlling for Practice {poor)
36
Cross tabulation of Attitude by Knowledge
Controlling for Practice (fair)
37
5.
.. . . . . . . ...
.. . . . ... .. .
32
33
34
6.
Crosstabulation of Attitude by Knowledge
Controlling for Practice (good) ••••••••••• 38
7.
Responses to Question 1: Frequencies
and Percentages . . . . . . . . . . . • • . . . • . . . . • . . • . . 41
8.
Responses to Question 2: Frequencies
and Percentages . . . . . . . . . . . . . . . . . . . • . . . . . . . 42
9.
C£osstabulation of Question 2 by Knowledge ••• 45
10.
Crosstabulation of Question 2 by Attitude
46
11.
Crosstabulation of Question 1 by Practice
47
12.
Crosst3bulation of Question 2 by Practice
48
13.
Responses to Question 3: Frequencies
and Percentages ••••••••••••••• ~ ••••••••••• 50
14.
~esponses
15.
Responses to Question 6:
to Question 4: Frequencies
and Percentages ··············~···~········ 52
and PercentC'.ges
Frequencies
•••••••••• ••••••••••••••••.
53
16.
Crosstabulation of Question 3a by
Question 4 ...••••••••••••••••••••••.•••••• 54
17.
Crosstabulation of Question 4 by
Question 6b ............•.......••..•••.••. 55
18.
Responses to Question 8: ~requencies
and Percentages . . . . . . . . • . . . . • • . . . . . . . . . . . . 58
vii
LIST OF TABLES (continued}
PAGE
TABLE
19.
20.
Responses to Question 5: Frequencies
and Percentages •••••••••••••••••••••••••.
Crosstabulation of Question 3b by
Question 5 ...
21.
$
•••••••••••••.••••••••••••••
23.
24.
_
63
Crosstabulation of Questim1 8 by
Question 5 ....... • •.•....•..•.......•.•. -...
22.
61
64
Crosstabulation of Question 5 by
Question 8 . . . . . . . . • • . . . . . . . • . . • . . • . . . . . . .
66
Crosstabulation of Question 4 by
Question 6c .•..........••....•..•........
67
Crosstabulation of Question Sa by
Question 5b ......•••.••. _. • • . • • • . • • • • . • • • •
68
Responses to Question 7: Frequencies
and Per9entages .....••.•..•.......•..•...
72
Responses to Question 9: Frequencies
and Percentages ..••.•••••••••••••••••••••
74
Responses to Question 10: Frequencies
and Percentages eeeeeeeeeee••·············
75
Responses to Question 11: Frequencies
and Percentages ··~·······················
76
Responses to Question 12: Frequencies
and Percentages .•••••••••••••••••••••••••
78
Crosstabulation of Question 9
by Question 11a .•••••••••••••••••••••••••
80
CrosstabuJation of Question 9
by Question llc ··~·······················
81
Responses to Question 13: Frequencies
and Percentages ··········••••o•••••·•····
84
33.
Crosstabulation of Question 13 by Attitude
85
34.
Crosstabulation of Question 13 by Practice
86
25.
26.
27.
28.
29.
30.
31.
32.
viii
LIST OF TABLES (continued)
TABLES
35.
36.
37.
38.
39.
PAGE
Responses to Question 14: Frequencies
and Percentages .........•......•.•..••.•.
89
Responses to Question 16: Frequencies
and Percentages ·········••a••••··········
92
Crosstabulation of Question 16 (Age)
by Attitude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
94
Crosstabulation of Question 16 (Age)
by Knowledg~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
95
Crosstabulation of Question 16 (Ag~
by Practice ••••••••••••••••••••••••••••••
96
i
40.
Responses to Question !7: Frequencies
and Percentages ••••••••••••••.••.••••••••
ix
98
ABSTRACT
PHYSICIANS:
KNOWLEDGE, ATTITUDES AND PRACTICES
REGARDING HOMOSEXUAL MALES WITH GONORRHEA OR SYPHILIS
by
Christine Marie Peterson Maqueira
Master of Public Health
A questionnaire survey inquiring into physicians•
attitudes, knowledge and clinical practices regarding
gonorrhea and syphjlis in gay males was sent to a random
sample of general practitioners, faffiily practitioners and
internists belonging to the Los Angeles County Medical
Association in Los Angeles, California.
Two hundred and
eight physicians (39.8 per cent) responded to the survey.
Analyses of the responses revealed the following:
a).
No relationship was found between the physi-
cians• attitudes toward gay male patients, their knowledge
of manifestations and treatment of gonorrhea and syphilis
in gay males, and their clinical practices in detecting
gonorrhea and syphilis in gay male patieQts.
X
b).
Half of the respondents indicated they sometimes
or always asked those patients who requested treatment
for g0norrhea or syphilis whether or not they had had a
homosexual contact.
c).
Those physicians who knew that rectal and
pharyngeal gonorrhea and syphilis could be asymptomatic
in gay males frequently did not examine or culture those
sites.
d).
The majority of physicians expressed no
negative attitudes toward male homosexual patients;
ever
how-
there was found to be a negative correlation between
physician respondents' ages and their attitude scores.
e).
There was a positive correlation betweenthe
number of gay male patients seen in the previous year
(1977) and belief that an understanding of the gay male
life style is important.
Based on these findings, the following recommendations were made:
a).
There should be a well-publicized ongoing
dialogue between the gay community and the meaical community.
It waB proposed that. this would result in more
gay males willing to be open with their physicians;
more physicians willing to ask about
and tQ perform three-site testing;
homose~ual
contacts
and possibly m0re
funda would be made available for research into control
of the venereal diseases in the gay male population.
xi
b).
Increased research should be done to discover
effective health education approaches to influence the
gay male population-to take more responsibility for
controlling the spread of the sexually transmitted
diseases within their own community.
c).
Research should be intensified to develop
vaccines effective against the
~exually
transmitted
diseases.
d).;
Medical students should receive more informa-
tion concerning gay life styles and their responsibilities
in treating male patients who might have contracted a
venereal disease through having had sex with another male.
In addition, specific information should be presented
in physicians' continuing education programs regarding
the diagnosis and treatment of gonorrhea and syphilis jn
gay male patients.
e).
All physicians who see patients with gonorrhea
or syphilis should be given "thre-e-site testing kits
these wouJ.d include media for uret.hral, rectal and
pharyngeal cultures, _anoscopes, and very specific
information on diagnosing and treating gonorrhea and
syphilis in gay
~ales.
xii
CHAPTER 1
INTRODUCTION
l?or several years it has been recognized by
public health experts in the Western world that the male
homosexual population makes a large addition to the
epidemics of syphilis and gonorrhea.
(34:741) (6:165} (36;76)
Sporadic efforts have been made to openly confront and
deal with this issue but progress has been minimal.
There
are several factors which nezd to be investigated as to
their possible contribution to this difficult problem.
These are discussed in the fo!.lowing paragraphs.
The subject of homosexuality has been a difficult
one fdr people in our society.
Discussions of the subject
generally become bogged d.own over the questions of whether
or not homosexuality is an immoral state, a si.ckness, a
natural sexual deviation, a
t~eatable
disease, an inborn
trait, or a crime.
Individuals· in the medical &nd public health
professions are often subject to the sarr.e reticence in
dealing with the subject of homosexuality be.cause of
religious or moral biases, or because of fenrs concerning
their own sexuality.
(77:324)
As a result, medically
1
2
adequate treatment of homosexual patients may be lacking,
either because of the negative attitudes of the health
professional towards homosexuality; or, indirectly,
because the professional fails to become adeqnately knowledgeable in the diagnostic and treatment modes of those
illnesses and diseases related to the sexual practices
of male homosexual patients.
(15:323) (60:44) (69:36)
The male homosexual patients themselves may be
apprehensive about possible condemnation or ridicule by
the physicians and paramedical personnel, in addition to
being fearful that their life style might be revealed to
employers and/or to families.
They may therefore con-
tribute to an epidemic by not seeking treatment.
An·additional factor which may have inhibited
progress in the control of gonorrhea and syphilis in the
male homosexual population is a lack of any systematic
training in nearly all medical schools regarding venereal
diseases in relation to male homosexual
{41:a-160) (45:54) (76:1519).
li~e
style3.
As a result, many physicians
may not know how to take adequate sexual histories, or
may not be aware of the need to examine all
releva~t ~ites,
and therefore signs or symptcms of gonorrhea or syphilis
may be missed.
Another reason for lack of diagnosis and central
may be that the homosexual patient would be ignorant of
many of the signs and symptoms of gonorrhea and syphilis.
3
Furthermore, the wide practice of anonymous sex among
male homosexuals is not conducive to contact tracing.
This further inhibits control of the spread of these
diseases.
Inadequate public health clinic facilities frequently result in long waits and inconvenient hours, which may
deter many patients from seeking immediate essential
help;
this may result in postponement of treatment and
an increased number of contacts before diagnosis and
treatment are carried out.
Finally, adequate funds for research and health
education in the field of the sexually-transmitted
diseases in the male
ally been available.
homosex~al
population have not gener-
This is largely related to negative
public attitudes toward homosexual1ty itself.
Funds for
research into the sexually-transmitted diseases in
genernl have been inadequate because the federal government, and those private agencies with grant money available, have aimed their priorities elsewhere.
(43:49)
Statement of the Problem
The main investigation of thie study will center on
·the question of whether Los Angeles County physicians'
attitudes, knowledge and clinical practices concerning
homosexual patients with syphilis or gonorrhea may
contribute to the increase in the incidences of those
p
'
4
diseases among this segment of the population.
Purpose of the Study
The main objectives of this study were to (1) assess
the attitudes of a sample of Los Angeles family physicians,
general practitioners and internists towards homosexual
men;
(2)
to assess the extent of the sample physicians'
knowledge regarding the diagnosis and treatment of gonorrhea and syphilis in homosexual men;
(3)
to assess the
diagnostic and treatmen.t practices (as reported by the
physicians themselves) of those physicians when dealing
!
with gonorrhea and syphilis :in homosexual men;
(4)
to
determine if there is a relationship among the sample
physicians' attitudes, knowledge and clinical practice
regarding the treatment of male homosexual patients.
Additional objectives of this study were (5) to
explore and-determine if there is any relationship between
the age of the sample physicians and their knowledge,
attitudes and clinical practice with male homosexual
patients;
and (6) to develop recommendations from the
above inforr.1ation regarding areas where health education
of the physicians and/or the male homosexual populaticn
might be effective in helping to reduce the rising incidence of syphilis and
gono~rhea.
5
The Hypotheses
The main null hypothesis is as follows:
there is
. no relationship between the attitude, knowledge and
clinical practice scores of the sample physicians as
they relate to male homosexual patients.
The second null hypothesis is that there is no
relationship between the physicians• ages and their
attitudes, knowledge or clinical practice scores.
The third null hypothesis is that there is no
relationship between the amount of information regarding
homosexuality which the physir.ians received in medical
school, and the attitude, knowledge and clinical practice
scores of the physicians.
Limitations of the Study
1).
Only physician members of the Los Angeles
County Medical Association (L.A.C.M.A.) were used for
the sample population.
The L.A.C.M.A. is affiliated with
the American Medical Association.
The results of this
study cannot be generalized to any physicians not living
in Los Angeles County nor to any physicians not members
of the L.A.C.M.A.
2).
The results of the analysis of the questionnaire
reflect only those answers which the physicians wished to
give.
It may be that the respondents answered the
questions as they felt they should be answered, instead of
,.. ,
""~""·~--··--"""-------"~~- .~..
. .
6
with their true feelings, knowledge or estimates of
clinical practices.
This is a limitation of all question-
naires,
3).
This investigator did not conduct structured
interviews with, or send questionnaires t.o, ·gay male
patients.
Therefore all data concerning feelings and
activities of gay male patients are taken either from
this investigator's personal experience in working with
gay male patients or from gay literature sources.
4).
The interview technique was not used beca.use it
would have yielded a far smaller sample, due to time
limitations, even though more in-dep·th information would
probably have been obtained.
Definition .:>f Terms
Bisexual: any person who has sexual intercourse with both
males and ferr.ales.
In this study the term bisexual
is included in the general definition of homosexual.
Family Physician: a physician member of the Los Argeles
County Medical Association listed in the membership directory under the category of F.amily
Practice by virtue of the decision of the American
Board of Family Practice Certificate Code 18.
Gay:
This word may be used interchangeably with homosexual, but specifically when referring to the general
subculture of all homosexuals.
It sho·.J.ld be noted
that while traditionally physicians have used the
word homosexual, most homosexual males prefer to
call themselves, and be called, gay.
General Practitioner: a physician member of the Los
Angeles County Medical Association listed in the
membership directory under the cate9ory of General
Practice by virtue of the decision of the
7
American Academy of General Practice Certificate
Code 060.
Homosexual:
for the purposes of this study any male
who participates -in sexual activities with another
male, either occasionally or on a regular basis.
This definition can therefore include married men
who have occasional homosexual contacts.
Internist: a physician member of the Los Angeles
County Medical Association listed in the membership
directory under the category of Internal Medicine
ty virtue of the decision of the American Board of
Internal Medicine Cer-tificate Code 20.
S.T.D. 's:
sexually-transmitted diseases.
Three-site test1ng:
inspection and c1.1l turing of the ure- _
thra, pharynx and anal-rectal region.
V.D.:
venereal disease. This term is to be used interchangeably in this study with "sexually-transmitted
diseases."
"V.D." has traditionally been used to
refer to the more common of the sexually-transmitted diseases, gonorrhea 2nd syphilis, whereas
the newer term, "sexually-transmitted diseases,"
is being used to include any disease which might
be transmitted in that manner, including shigellosis
and_ hepatitis.
Justification for the Study
In Los Angeles County the number of cases of botlt
syphilis and gonorrhea has markedly increased.
Reported
syphilis, which had been on the decline_from 1974 tnrough
1976, increased by 10.9 per cent in 1977.
Reported
goncrrhea has also been increasing steadily :or three
years in Los Angeles County, although the most marked
increase was from 1975 to 1976, with an increase in case
ra~e
of 8.3 per cent per 100,000 estimated population.
(13:ii)
8
V.D.
Ed~cational
Programs
Los Angeles County has been considered to·be one
of the most innovative counties in the United States on
the subject of educational and treatment programs for the
sexually-transmitted diseases.
For example, as early
as 1971, a venereal disease information program had
been initiated in the Los Angeles Schools, and it .was
claimed that "eighty-six per cent of the young people in
schools of Los Angeles County are now being instructed in
venereal disease."
(68:10)
The Men's Venereal Disease Clinic of the Gay Com1
munity Services Center in Los Angeles has been open since
1972.
Wh!le i t was initially financed only by donations,
the County of Los Angeles Later contracted to supply
$10,000 worth of medical supplies yearly.
In 1974 the
Center for Disease Control (C.D.C.) provided grant funds
of $130, 460. ·W'hich made possible twelve clinic hours a
week, a bathouse screening program, and an educational
and community outreach program.
(50:50)
Since then the
clinic has been expanding steadily, so that in 1977 it
w~s
by far the largest gay venereal disease clinic in the
United St&tes, with an average of 1253 patient visits a
mont1:1.
(3)
The Bogue Study was
d
research project conducted
in Los Angeles County which investigated patients•
knowledge levels (regarding the. S.T.D.'s), compliance
9
with medical instructions, and responses to educational
programs on the S.T.D.'s.
The final results of the study
have not yet been made public.
A series of videotapes
developed for the Bogue study's education section {4) was
filmed and set up in Los Angeles Public Health clinics
in 1977 to be shown to patients during venereal disease
clinic hours.
These videotapes were frank and graphic,
and included a large amount of information on venereal
diseases in homosexual men.
In addition, several other programs for public
information have become availcble in Los Angeles County,
including a "V.D. Hotline," funded by the county and
staffed by volunteers.
Assumptions Regarding V.D. in :Homosexuals
In spite of these programs the reported gonorrhea
and syphilis rates, particularly in homosexual men
(35:740) continue to spiral in Los Angeles, as in the
rest of the country.
Many assumptions have been made by
various authors about factors which may contribute to the
problem and possible modes of intervention.
Some of
these assumptions are as follows:
a).
educational programs directed at patients
with gonorrhea and/or syphilis will help
decrease the incidence rate of these diseases.
(the Bogue Study is testing this assumption.)
(4)
b).
promiscuity among gay men is primarily responsible for the increase in the sexually-
10
transmitted diseases in that population.
(33:46) {36:76)
c.)
physicians generally hold negative attitudes
toward homosexual men. This is-an assumption
held by many homosexuals.
(45:221) (36:76)
(31:815) (67:14-16)
d).
physicians do not hold prejudices against anyone • ( 2 3 : 16 6 1 )
e).
many more homosexual men attend public health
clinics rather than go to private physiciansv
(75:41)
f)•
physicians can recognize homosexual patients
on the basis of actions or looks.
(59:199)
(19:83)
g).
if physicians are better informed about the
sexually transmitted diseases they will be
less likely to miss cases of gonorrhea or syphilis through inadequat3 history taking or
diagnostic practices. (64:2}
Each of these assumptions has been used as the
basis .:>f, or a factor in, programs developed to combat
venereal diseases in this country.
Fur instance, there
are many and varied educational programs aimed at increasing patient knowledge about the
S~T.D.
's.
However, no
one has yet demonstrated that an increase in patients'
knowledge will result in a decrease in the incidence
rates of the diseases.
As another example, assumption (g) states that
educating physicians regarding the S.T.D.'s will result
in their missing·or misdiagnosing fewer cases of the
S.T.D. 's.
It may be, however, that fear of homosexual
men, rather than lack of knowledge, is the factor which
causes some physicians to miss dicgnoses-or inadequately
11
treat cases of gonorrhea or syphilis in homosexual men.
Gonorrhea and Syphilis in Gay Men
Gonorrhea and syphilis present a clinical
pi~ture
in homosexual men that is different from that in exclusively heterosexual men.
Since rectal and oral sex are
two types of sexual activity in which homosexual men
very frequently participate, there are two more potential
disease sites besides the urethra:
the anal-rectal area.
the oropharynx and
Chancres, or sores, inflammation
and drainage in these areas may either be undetected
becaus~
they are asymptomatic, or they may appear to be
caused by another disorder.
Rectal pain and itching, for
instance, may be thought to be caused by hemorrhoids;
a
chancre in the anal area, especially one with a superimposed infection, may appear to be
fissure.
(33:47)
a~
inflamed anal
Gonorrhea of the pharynx can resemble
streptococcal sore throat;
inflamed tonsilar crypts can
be mistaken for tor1silli tis from another cause.
( 73:96)
Only with a culture or, in the case of syphilis, a blood
test can one be certain of the cause.
During the year that this investigator·worked as a
nurse at the Men's Venereal Disease Clinic of the Gay
Community Services Center in Los Angeles, several patients
stated to her that private physicians they had previously
visited for routine checkups or treatment of suspected
venereal disease, did not perform rectal pr pharyngeal
,.
12
examinations or cultures.
Some of these patients stated
that they had told the physicians they were homosexual.
The investigator discussed this information with the gay
clinic physicians.
It was generally agreed by these
physicians that there could be a potentially large number
of undiagnosed cases of rectal and pharyngeal gonorrhea
and syphilis due to lack of examination and cultures of
these areas.
The investiagtor was encouraged by the
physicians to conduct a study concerning this possibility.
One of the most important reasons for this study
lies in its intent to test the bases of some of the assumptions listed on page 7, and thereby indicate where definitive actions might be taken to improve control of syphilis and gonorrhea in the male homosexual population.
While this study deals mainly with homosexual men, it is
also relevant to the majority of (heterosexual)
people~~
A great many men are not exclusively homosexual, but rather
bisexual.
In having sexual relations with women they
may spread the disease outside of the 1nale homosexual
population and increase the general incidences of gonorrhea
and syphilis in the heterose1:ual population at large.
(35~741)
(33:47)
CHAPTER 2
REVIEW OF THE LITERATURE:
AN HISTORICAL PERSPECTIVE
Homosexuality in Med:i.cal Literature
Before the 1950•s
A review of medical textbooks before the 1950•s
reveals that few medical personnel of that time were
a-w-are of the possibility that rectal gonorrhea or rectc.l
syphilitic chancres could occur in homosexual men.
In-
formation and research on these two diseases in other
-sites, however, was extensive.
Physicians• attitudes
toward homosexuality at this time were shaped by prevaJling psychiatric evidence, largely derived from studies
by those schooled in Freudian Psychology, that homosexuality is a disease due to arrested personality maturation.
(21)
Medical literature on the subject of homosexuality
until the late 1950•s, therefore, dealt almost exclusively
with various psychiatric and medical treatments for
homosexuality;
treatises were on specific sociological
or psychological attributes of the· .. afflicted
(2)
(27)
11
patients.
Very few medical articles written during the
1950 1 s dealt with the subject of venereal disease i;n
homosexuals.
The notable exceptions were usually medical
13
14
articles by proctologists.
They were the only non-
psychiatric physicians who regularly treated homosexual
men (because of rectal disorders resulting from rectal
intercourse)
(37), and were some·times able to identify
homosexuals as such.
One example was an article by
G.M •. Fergen, "Proctologic Disorders in Sex Deviates."
He claimed:
"A physician's responsibility in these cases
is one of diagnosis and treatment. Possible
alteration of the degree of homosexuality should
be left to the psychiatrist.
I~ is important
that the proctologist learn to recognize the
homosexual, understand his problem, and employ
the tact and skill which will make the examination
and treatment successful."(19~83)
In a period when homosexuality was considered a
treatable mental illness, Fergen's emphasis on the
diagnosis and treatment of venereal diseases in homosexuals
and on the importance of the physiciailS' manners toward
these patients, was unusual.
The fact that his a=ticle
was published in a non-speciality journal (California .
Medicine), rather than a proctologic journal, meant that
physicians of many specialities were exposed to a concept
that was rarely to be stated until the 1970's.
The Wolfenden Report
In 1957, The Wolfenden Report, a Report of the
Committee on Homosexual Offenses and Prostitution (12)
was published as a result of a study conducted in England
by several prominent British citi.:?:ens, among whom were
15
physicians and psychiatrists.
The report led to the
legalization in England of homosexual acts between
consenting adults.
Following the report, studies inves-
tigating homosexualit:y as an alternative life style rather
than a necessarily pathological state began to appear in
the medical and psychological literature in England.
By the end of the 1960's, articles written by
physicians other than psychiatri..sts or proctologists about
homosexuals with venereal disease had become common in
England, New Zealand and Australia (20) (32) (33) (65), areas
where the Wolfenden Report had had the most. effect on
laws and social mores regarding homosexuality.
The 1960's: a Dilemma for American Physicians
In the United States during the 1960's, homosexuality
was still generally a subject for discussion in terms of
its morality, its effects on the younger generation, its
supposed predominance in the lower social classes, and
physicians• abilities to deal witr. homosexual patients
per se.
(41) (31)
the Physician"
Heersema•s article "Homosexuality and
is a good example of the dilemma physicians
were facing because of the contrasting influences of the
more liberal British medical attitudes an1 the still
important influences of Freudian psychology.
to Heersema:
According
16
"Because of the opinions expressed by some
physicians, a majority of homosexuals, by reason
of fear of condemnation, are reluctant to seek
medical assistance, or do so with heightened anxiety.
The hope for the professional and for the homosexua~
depends on an empathic attitude of the physician,
and this in turn rests on an unde~standing, hopefully developed by a working relationship with
psychiatrists. The arrest of personality growth,
for example, at a homosexual level, should be a
challenge to the physicians. •
To speak of
a healthy, happy homosexual is a euphemism, similar
to speaking of a cripple or a partially blind
person as being 'happy. ' Though he may rise above
the disability, he is at all times aware of it
and of its inhibiting force." (31:815)
This investigator found only two articles in
American medical journals published during the 1960's
which referred to syphilis in homosexual men (5) (69},
and none about gonorrhea in that population.
Taire and Lugar's article
However,
"Early Infective Syphilis,"
1960, was exceptional in that the authors anticipatec
by more than a decade the more realistic and knowledgeable
views of the 1970's regarding homosexual patients.
They
write as follows:
"In view of the patients' reluctance to spon------------~----~t~a~n;e~o~u;s~l;.y~·~a~d~m:i:t~the mode of infection, it became
imperat1ve for physi<erans-te-p&ssess-a-cLinic______________~-index of suspicion directed toward the detecting
of the atypically located lesion •
••• it is apparent that attempts to identify
a male homosexual based upon physical appearance
or mannerisms or mental status are futile.
As in
any interpersonal relationship, the physician's
attitude toward the homosexual patient is of importance in the therapeutic process. The desireable
sympathetic approach toward the patient may be
complicated by the physician's own attitudes,
emotions and judgements relating to homosexua~
activity. An awareness of his own attitudes and
feelings will facilitate a non-judgemental physicianpatient relationship. {69:36)
17
In 1969, following a period of widely publicized
gay activism, the subjects of homosexuals and sexuality
began to be discussed in general (non-psychiatric) medical
journals.
The journal Medical Aspects of Human Sexuality
began publication and quickly gained a large readership
in the medical world.
A survey by Pauly and Goldstein of
physicians' attitudes toward premarital and extramarital
intercourse was published in this magazine, and the authors
concluded that:
"Cultural attitudes toward such sexual behavior
as premarital intercourse are changing. This
change has already begun to reflect itself in thP
attitudes of younger physicians, who appear to
be more knowledgeable, more comfortable and more
positive in their attitudes toward people with
sexual problems than older physicians." (61:45)
The Early and Mid-1970's:
Sexual Liberalism
in Medical Literature
Non-p·sychiatric medlcal articles on homosexuality
began to o.ppear with increasing frequency in American
medical journals in the early 1970's.
Golds~ein
While Pauly and
found that physicians' attitudes toward sexual-
ity in general were becoming more liberal, those authors
stated in an article published six months earlier,
regarding a poll of Oregon physicians:
"The majority of physicians acknowledge some
degree of discomfort • • • in treating the medical
problems of a person who appears to be a male
homosexual. There is a positive relationship
between the physician feeling comfortable in
18
treating patients and his feeling comfortable in
the discussion of sexual problems in ger;eral."(60:44)
As the nineteen seventies progressed there was a
definite evolution to be noted in American medical
literature regarding homosexuality in general and venereal
disease in homosexual men.
In the early seventies the
latter was still considered mostly as a newly-recognized
phenomenon requiring increased attention.
A good
example was noted by Pariser and Marino in "Gonorrhea
Frequently Unrecognized Reservoirs:"
"A second group
of patients not usually considered a potential source of
infection is the asymptomatic male."
A.nd,
"Rectal goner-
rhea is a • • • clinical type of gonorrhea which is rarely
considered a potential source of transmission of the
disease."
(59:199) {44:136)
From the middle 1970's on there was increasing
recognition that (1) gonorrhea and syphilis in homosexuals
were common, but different enough from manifestations of
the same diseases in heterosexuc.ls that they required separate modes of diagnosis and treatment;
and (2) some
modification in the physicians' approach to gay patients
might be required if successful diagnosis and treatment
were to be accomplished.
(8) (17) (47)
During the early to middle 1970's, therefore,
emphasis in medical literature changed from discussions
of V.D. in homosexuals as a new, poorly recognized
phenomenon, to (later) treating the subject as if it were
-"·- - - - - - - -
19
common knowledge, but recognizing that new approaches to
the diagnosing and treating of the diseases in the male
homosexual population were
neeC:~d.
From 1976 to the Present:
an Emphasis on Aggressive Casefinding
Since 1976 there has been an increasing emphasis on
aggressive casefinding and on patient education in the
gay male population.
To a large extent this is due to
greater public recognition of the gay free clinics, and
to many medical journal articles appearing in this country
which are written by clinic personnel.
The papers from
a symposium on venereal disease and gay men were publ1shed
in the April-June, 1977 issue of the journal Sexually
Transmitted Diseaaes.
(50) (58)
These papers, plus an
article in the American Journal of Public Health, August
1977 (35), described the clinic facilities, bathhouse
screening programs and the expanding educational programs
of the gay clinics in Chicago, Los
~ngeles
and Denver.
It is important to note that the gay press has
published several articles and books on venereal disease.
(The Advocate Guide to Gay Health, by Fenwick, is one of
the more thorough and accurate books.)
(18)
One of the
most widely read articles was in the Advocate, a nationally distributed newspaper for male homosexuals.
The
article summarized the philosophy of most of the gay
20
clinics regarding venereal diseases in gays:
"We Lgay§/ have a lot better chance of doing
about it. We are a lot more open
about V.D. -- sort of like it's an occupational
hazard. We're not so hung up in the morality
and are much more in tune with the problem."
somet~ing
(67: 18)
Since the latter part of 1977, at least two
articles have been published in the medical literature
which squarely face the problem of how physicians'
attitudes and lack of knowledge regarding homosexuals
with venereal disease might be inhibiting control of the
spread of these diseases.
An article in "Impact," from
the American Medical Association newsheet, American
Medical News, points to "gaps of training in the S.T.D.'s"
in medical schools.
The article states that embarassment
by both the physician and the patient, and lack of money
for screening and research are major hurdles to be
overcome in order to control the spread of venereal
diseases.
(64)
Felman and Morrison, in their article published in
the Journal of the American Medical Association (J.A.M.A.)
in 1977 conclude that:
"To control the spread of the sexually transmitted diseases, their rate of occurre~ce among
all of the high-incidence groups in our society,
including the homosexu~l male,· must be reduced.
Only through motivating gay males to seek regular
examinations will we be able to treat those \iho
are infected. We, therefore, must offer our health
care services in a way that is effective and that
minimizes the anxiety many homosexuals associate
with examination and treatmet}t for se.;mally transmitted diseases." (17:2047)
21
It can be seen, therefore:, that before the late
1960's, the subject of venereal diseases in homosexuals
·was rarely treated in medical journals.
Both in Britain
and America recognition and treatment of the subject of
homosexuality as other than a mental illness occurred in
medical journals following its
public attention.
In Britain,
the cause of this attention;
receiving widespread
~he
Wolfenden report was
in the United States, gay
activism caused the public to take notice of the subject
of homosexuality.
In the U.S. venereal diReases in the male homosexual
population received increasing emphasis in medical
literature as the 1970's progressed.
Early medical
literature focused on the subject as an unusual phenomenon;
as the 1970's progressed, the literature focused on
diagnostic and treatment modes, and then increasingly on
·the physician's responsibility to find acceptable
approaches to gay patients which
~ould
result in those
patients being more receptive to attempts to control the
spread of the diseases.
CHAPTER 3
METHODOLOGY
The objective of this study was to investigate the
relationships among the respvndent Los Angeles County
physic~ans•
attitudes, knowledge and diagnostic and
treatment practices in regards to male homosexual
patients requesting treatment for gonorrhea and/or
syphilis.
The purpose behind the study was to find out
if some cases of rectal or pharyngeal syphilis or gonerrhea might be overlooked by the physician because of
inadequate diagnostic practices;
and, if so, whether
the inadequacy might be related to the physicians•
knowledge or attitudes regarding male homosexuals with
rectal or pharyngeal gonorrhea or dyphilis.
The Research Design Plan
The investigator proposed to conduct an exploratory
study using the mailed survey questionnaire as the method
of collecting data.
Therefore, the desired result was
a large number of responses, indicating as nearly
~s
possible the full range of attitudes, knowledge and
clinical practices.
22
23
The purpose of an exploratory study is
11
to gain
familiarity with a phenomenon or to achieve new insights
into it, often in order to formulate a more precise
research problem or to develop hypotheses.
11
(66:90)
While there have been a few speculative studies concerning
physicians• attitudes toward homosexuals, as was discussed
in the Literature Review sectioP, this writer found no
in-depth studies investigating physicians•
knowledg~
or
practices regarding homosexual gonorrhea or syphilis.
(One article which reported results of a questionnaire
on physician attitudes. and diagnostic practices was
published in 1978,
(24) after the questionnaire had been
mailed and the bulk of the research for this thesis had
been done.
Further information concerning the sample,
the form of the questions and the statistical analysis
was not made available to this writer when requested.)
In keeping with the aims of an exploratory study
the questions in the questionnaire covered a wide
range of subject matter.
In fact, all subjects were
included which this investigator and the consultants tc
the research project felt might contribcte to the
for~ula­
tion of an hypothesis regarding physicians• approaches
to diagnosis and treatment of homosexual patients with
gonorrhea or syphilis.
An intensive literature search for studies similar
to this one was conducted through the utilization of the
24
the Medlars/Medline Search Request available through
the California State University, Northridge.-
Me-dlars/
Medline is a computerized medical bibliographic search
facility which draws upon the comprehensive Index Medicus
(54) for its information.
The facility is sponsored by
the National Library of Medicine in Washington,D.C.
Using
the extensive amount of information received from the
Medlars/Medline references on the subject, in addition
to information gleaned from many informal discussions
with physicians and gay male patients,·an exploratory
questionnaire was carefully
designed.
.
i
This
qu~stionnaire
was mailed, together with an introductory letter and an
enclosed, stamped return envelope to each of the physicians
selected at random as the sample population.
The sample
population was randomly selected from the 1976-77
Directory of Members of the Los Angeles County Medical
Association~
(28)
The researcher selected those physicjans
listed under the categories of general practice, family
practice and internal medicine, from all seventeen
L.A.C.~.A.
districts located in metropolitan Los Angeles,
Calif~rnia
end surrounding suburban communities.
projected sample size was 600.
The
There were approximately
3500 general practitioners, internists and family practitioners listed in the 1976-1977 Directory.
An exact
number is not available because many of the physicians
of one category
w~re
also listed in either or both of the
25
other two categories.
The investigator selected these three particular
physician categories based
~n
the following information.
A (civilian) male patient who suspects that he might have
gonorrhea or syphilis has fiv9 options as to types of
medical facility he can attend:
facility;
clinic;
(1) a public health
(2) a hospital emergency room;
(3) a free
(4) a private non-specialized physicians• office
(i.e. a general practitioner, family practitioner or
internist; of (5) a specialist's office (i.e. a urologist
or proctologist.)
In Los
Angeles
County in 1977, 59.8
.
l
per cent of the syphilis cases and 43.4 per cent of the
. gonorrhea cases were reported by private physicians.
(13)
There was no breakdown available as to what percentage
of the reporting physicians were specialists of generalists.
However, most pat1ents will see a general physician
for most complaints, simply because the majority of
specialists only accept patien·ts by referral from another
(usually generalist) physician.
There·is an exception to this rule in Los Angeles
Coun~y:
a few gay proctologists and urologists have
restricted t.heir practices primarily to homosexual men,
and do not require referrals to see these patients.
However, the number of patients seen by these physicians
is unavailable since the physicians do not advertise their
gay parctices and in fact their.patients come to them by
26
word of mouth referral.
A pretest was designed to test the validity of
the .survey questionnaire.
Copies of the pretest survey
questionnaire were mailed to a random sample of twenty
physicians (general practitioners, family practitioners
and internists).
A response rate of thirty per cent was
received by the end of four weeks.
The final questionnaire was designed with the aid
of two physician-researchers who had had previous
experience in developing questionnaires directed towards
physicians.
In addition, the comrr1ents from the pre-test
respondents were given full consideration in the development of the final questionnaire.
The Design of the Questionnaire
Five types of questions were included in the
research tool:
etc.
(2)
(1) demographic questions, age and sex,
"estimation" questions requiring the physicians
to make numerical estimates based on their memory:
for
instance, how many patients whom they believed to be
homosexual or bisexual had they seen during the year;
(3) attitudinal questions:
for instance, "do you feel
that homosexualty in men is a social threat?";
(4) ques-
tions assessing the physicians • knowledge: · i.e. "is
rectal gonorrhea frequently asymptomatic?";
and (5) "clin-
ical practice" questions, asking the physicians to state
27
whether or not they practice a certain diagnostic procedure under specific circumstances.
("Do you ins.pect
his throat and rectum for signs of infection, if the
patient is a married man? 11 ) .
The -_.questfGnnaire was designed to elicit the largest
physician response possible by keeping the questions
short, simple, interesting, non-judgemental and relevant.
Additional factors which may have influenced the 39.8
per cent response rate were:
a cover letter signed by
a well known and respected Los Angeles physician;
cover letter printed on the
~etter-head
the
stationary of
the organization sponsoring the study, the Los Angeles
Veneieal Disease Information Council (L.A.V.D.I.C.};
the
total anonymity of the questionnaire; and the stamped,
self-addressed enclosed envelope.
At the same time the investigator attempted to
insure reliability and validity.
ways.
This was done in two
The pre-test questionnaire included many more
questions than the final instrument.
Eliminated or
reworded were all questions which it was found could be
interpreted differently by different respondents.
Some
of the questions were asked in more than one way, so
that internal validity could be checked:
that is, if
there proved to be a high correlation between the answers
of two very similar questions, some degree of internal
validity could be assumed.
28
The answers to the questions measuring physician
attitudes, knowledge and practice were coded so ·that a
responde~t
would receive a high, median or low score for
each type of question.
A high degree of knowledge on
the subject of gonorrhea and syphilis in gay men, a
l
positive attitude toward homosexuality in men, and
adequate clinical testing and diagnostic practices were
all given correspondingly high scores, and
opposite,
~he
low scores.
Computer analysis of the data was accomplished
through use of the Statistical Program for the Social
Sciences ( S. P. S. s. ) .
(57)
The questionnaire contained eleven attitude
questionst of which nine were shown to be internally
valid by use of correlational analysis.
These nine were
used in defining the physician attitude score.
four were used to report percentage figures.
The other
Four
knowledge ..:J.Uestions and five practice questions were also
selected t.o give cumulative scores to each physician, to
assist in chi square analysis of the responses.
lt 2, · and 3 (pages 32
signed to each
Tables
through 34 ) present the values as-
respo~se,
plus the total possible score
for the knowledge. attitude and practice questions,
respectively.
as to order
The answers to the questions were varied
of value, so that the physician respondents
would discern no pattern which
~ght
influence their choice.
29
The Response
The replies to the questionnaire were received
from one to five weeks after they were sent out.
Approx-
imately twenty questionnaires were returned unopened
because the addressee had moved or was deceased.
Many
of the respondents did not answer all of the questions.
(Non-response to a question was considered a valid
response, and this factor was included in the statistical
analyses.)
Frequently comments were included indicating
that the question was not relevant to their practice.
All questionnaires with any answers at all were included
in the analysis.
The investigator felt that even
incomplete questionnaires could reveal more informati0n
about this relatively new field than was held before.
For instance, eighty physicians (39 per cent) filled
out only the first two questions (these asked the number
of cases of gonorrhea and syphilis seen in 1977, and the
nurr~er
of those patients whom the physician believed to
be homosexual or bisexual) because they felt that they
had not seen any homosexual or bisexual men in their
practices the previous year.
This becomes relevant when
the question of how a physician knows a patient is
homosexual, and how many homosexuals he may actually see,
are considered.
and the Lesbian,"
In a parallel study "The Gynecologist
(27) 43.6 per cent of the
respond~nts
stated that they saw no patients whom they suspected
30
might be lesbians.
The author concluded that
"at least 4% of gynecological patients would be
homosexual and would be well represented jn the
average busy gynecologist's practice.
I think it
is likely that many lesbians • • • go unrecognized
in the gynecologist's office." (27:482)
CHAPTER 4
RESULTS AND DISCUSSION
In this chapter the results of the questionnaire
are analyzed in detail, using chi square tests and
(where relevant} Pearson
~orrelation
coefficients.
chapter is divided into twelve sections:
Attitudes and Clinical Pr.actice;
The
{1) Knowledge,
{2} Number of
Patien~s
!
Seen;
{3} Identifying the Homosexual Patient;
ing Patients about Homosexual Contacts;
Infection;
{4} Ask-
{5} Asymptomatic
(6} Three-site Examination and Culturing;
(7} Treatment of Rectal and Pharyngeal Gonorrhea;
(8) Attitudes toward Gay Male Patients;
(9) The Impor-
tance of Understanding the Gay Male Lifestyle;
(10} Med-
ical Schoc,l Training regarding Homosexuality;
(22) Age
of Respondents;
In each
and (12} Sex of Respondents.
section relevant statistical results are presented under
the subheading titled "Results";
then a discussion of
the resul t.s and material from other literary sources :i.s
presented under the subheading "Discussion."
Tables 1 through 3 give the assigned values and
categories for the attitude, clinical practice and
knowledge
questions~
In each
c~se
31
a lower score is given
Table 1
VALUES FOR KNOWLEDGE QUESTION RESPONSES
Question
#7.
#8.
possible response
If you treat a male for penile gonorrhea
do you believe that the dosage of antibiotic you use is sufficient to cure any
rectal or pharyngeal gonorrhea that may
also be present?
In your professional opinion are pharyngeal and rectal gonorrhea frequently
asymptomatic?
yes
no
undecided
pharyngeal:
rectal:
#13. Do you"believe that it is important
for a physician to have some under~
standing of the male homosexual life
style and sexual activities in order
to adequately diagnose and treat him
for syphilis and gonorrhea:
value
yes
no
undecided
yes
no
undecided
yes
no
sometimes
3
1
2
3
1
2
3
1
2
3
1
2
********************************
possible total
score
1 through 8
9 through 10
11 through 12
meaning
poor
fair
good
w
1\.)
Table 2
VALUES FOR ATTITUDE QUESTION RESPONSES
Question
possible response
#9.
rather not
I don • t mind ·
undecided
Would you rather not have openly
homosexual men as regular patients?
#10. Will you accept the referral of
a homosexual for treatment?
#11. Do you feel that homosexuality in
men is:
(a) a social threat )
(b) an illness
)
(c) immoral
)
#12. What are your own feelings when a
male homosexual patient asks you
for treatment?
dislike
)
discomfort )
acceptance
*********************************************
Rgssible total score
1 through 9
10 through 14
15 through 19
yes
no
undecicjed
--yes
no
undecided
value
1
2
0
.....
~
1
0
1
2
0
yes
no
(x)
( )
2
yes
no
(x)
( )
2
1
1
meaning
negative
neutral
positive
w
w
:.r..
i
Table 3
VALUES FOR PRACTICE QUESTION Rlf!SPONSES
Question
#4.
#5..
#6.
possible response
How often do you ask your male patients who
request treatnent for possible syphilis or
gonorrhea is they have had a homosexual contact?
always
sometirries
rarely
never
For those men .whom you believed to be homosexual
or bisexual, what sites did you examine and/or
culture for gonorrhea or syphilis?
(a)pharyngeal ) always
(b)rectal
) sometimes
never
value
4
3
l
2
1
3
2
1
If a patient whom you know to be a married man
asks you for treatment of gonorrhea,
(a) do you ask him about sexual relations )
yes
3
outside ot his marriage?
)
no
1
(b) does your inquiry include questions
}
sometimes
2
about homosexual contact~?
)
(c) Jo you inspect and/or culture
} ***********************************
his throat and rectum for
) possible total score
meani~
signs of infection?
) 4 through 8
poor
9 through 12
fair
13 through 16
good
w
ol:ao
35
a more negative definition, and a high score the opposite.
For example, an attitude score of 6 falls in the category
assigned a "negative" attitude.
Conversely, a knowledge
score of 11 falls in the "good" category for knowledge.
Knowledge, Attitude and Clinical Practice
Results.
Tables 4,5 and 6 show crosstabulations of knowledge and attitude controlling for each of the three
value categories of practice.
the
c~i
With all three values,
squares are not significant.
The main null
hypothesis for this study is accepted:
there is no
relationship between the attitude, knowledge and clinical
practice scores of the physicians sampled ih this study.
Discussion.
The traditional assumption
~n
the health education
field has been that where one had adequate knowledge of
a subject and a positive attitude t.owa.rd that subject,
positive behavior would follow.
Although this knowledge-
behavior-attitude hierarchy ha3 lately been subjected
to a great deal of criticism within the health education
fie!~,
it is still a widely held assumption in other
disciplines.
In their article "Physicians• Attitudes
Toward Premarital and Extramarital Intercourse,"
Pauly
and Goldstein suggest the following:
"There is a defini·te relationship between
personal attitudes and clinical behavior,
36
Table 4
CROSSTABULATION OF ATTITUDE BY KNOWLEDGE
CONTROLLING FOR PRACTICE
Practice:
Response
'
poor
Knovhedge
!
fair
poor
good
Attitude
n
n
n
nec;ative
1
4
4
9
neutral
0
6
2
8
positive
2
9
5
16
3
19
11
33
total
x2 not significant
. total
37
Table 5
CROSSTABULATION OF ATTITUDE BY KNOWLEDGE
CONTROLLING FOR PRACTICE
Practice:
fair
Knowledge
Response
poor
fair
good
Attitude
n
n
n
total
negative
1
4
6
11
neutral
4
6
5
15
positive
0
10
6
16
total
5
20
17
42
x2
not significant
38
Table 6
CROSSTABULATION OF ATTITUDE BY KNOWLEDGE
CONTROLLING FOR PRACTICE
Practice:
good
Knowledge
Response
poor
fair
good
Attitude
n
n
n
negative
0
4
6
10
neut:ca.l
0
6
5
11
positive
1
6
8
15
1
16
19.
36
total
x2
not significant
total
39
especially in the sphere of human sexuality. We
have demonstrated this tendency in regard to the
relationship between feeling comfortable in the
discussion of sexual matter, and the frequency of
obtaining a sexual history and identifying significant sexual problems in patients." (61:40)
The results of this present study
tiate this assertion:
do not substan-
among the physicians sampled,
those whose score for clinical practice in detecting
and treating rectal or pharyngeal gonorrhea or syphilis
is high, do not necessarily have a high level of knowledge
regarding gonorrhea and syphilis in gay men (according
to the stated parameters) nor do they necessarily have
a positive attitude score toward gay male patients.
This may mean that educational programs designed
to further educate the physician about- gay male venereal
diseases (if most physicians are similar to the respondents in this respect), or to increase his acceptance of
the gay life style, might be associated with improved
clinical practice in detecting gonorrhea or syphilis
in gay men.
There may be other factors which have more
influence on the physicians' clinical practice scores,
such as their personal fears regnrding homosexuality or
previous experiences with male homosexual patients.
The remainder of the sections in this chapter
present results of crosstabulations of questions from
each of the three categories (attitude, knowledge and
clinical practice) in order.to define more specifically
those factors which contributed to the acceptance of the
40
null hypothesis.
Number of
~atients
Seen
Results.
Table 7 summarizes the approximate number of cases
of suspected gonorrhea and syphilis in all males which
the physicians remembered seeing during the previous
year (1977).
Fifty per cent of the physicians indicated
that they had seen from one to ten cases;
per cent saw ten to fifty cases.
{7.8 per cent) stated they
~aw
I
thirty-four
Only fifteen physicians
no cases of qonorrhea or
syphilis during the previous year.
Table 8 summarizes the number of male patients with
possible gonorrhea or syphilis whom the physicians
believed to be homosexual or bisexual.
Th.i.rty-three per
cent of the physicians felt that they had seen no male
bisexual or· homosexual patients.
Approximately sixty
per cent remembered seeing from one to ten, and 6.7
per cent tad seen more than ten patients.
Therefore, a
full two thirds of the physicians were aware of having
seen one or more male homosexual patients with symptoms
of gonorrhea or syphilis during 1977.
DiSCllSSion.
It is not clear how much reliance can be placed on
a physician's estimate of cases of gonorrhea previously
seen.
Gale and Hinds (22) mailed a questionnaire to
41
Table· 7
RESPONSES TO QUESTION 1:
Question No. 1:
FREQUENCIES AND PERCENTAGES
Approximately how many cases of
suspected gonorrhea and syphilis in
all males did you see last year?
Response
absolute
frequency
adjusted
frequency
(per cent)
cumulative
frequency
(per cent)
none
15
7.2
7.8
1 to 10
99
51.3
50.1
10 to 30
51
26.4
85.5
30 to 50
14
7.3
92.7
__u.
7.3
100%
100.0
100%
more than 50
193
missing cases:
15
42
Table 8
RESPONSES TO QUESTION 2:
Question No. 2:
FREQUENCIES AND PERCENTAGES
Of those men who had gonorrhea or
syphilis or their symptoms approximately
how many did you believe to be homosexual
or bisE;::xual?
!
Response
absolute
frequency
adjusted
frequency
(per cent)
cumulative
frequency
{per cent)
none
59
33.0
33.0
1 to 5
98
54~7
87.7
5 to 10
10
5.6
93a3
10 to 30
9
5.0
98.3
_3
179
_j,_J_
100.0
100%
more than 30
missing cases:
29
100%
43
physicians concerning the number of cases of urethritis
seen in King County, Washington in 1974.
They concluded:
•••
in a busy practice, a physician faced
with a mail questionnaire such as ours almost
certainly did not go to his or her records to
verify urethritis cases • . • • If one or more
cases were seen, the number recorded in our
retrospective survey may well have been subjected
to a rounding bias which overestimated the cases
seen.
In general, the number of cases reported
as they occurred (prospectively) was only 10 15 per cent of the number reported retrospectively.
Physician recall of gonorrhea cases in Alaska has
been recently shown to exceed cases actually seen,
as validated by a record ..:eview." (22:23)
11
It is important to note, regarding the Washington
report, that while many of those cases were not reported
to the Health Department, they probably were seen by the
physician.
According to Sandholzer, ."private physicians,
who treat most cases of gonorrhea and syphilis, .tend to
underreport these cases
particularly gonorrhea."
L t9. the Health Departmen.:!J,
(64:1)
Furthermore, it is
unclear how the degree of over-reporting (or under-reporting) may vary either with number of cases seen, or with
the area of the country.
There may be some unknown
factors influencing the number of cases recalled, which
differs from Washington to Alaska to Los Angeles.
In any case, it is quite possible that the number
of patients with symptoms of syphilis or gonorrhea were
J
over-estimated by the physicians.
However; it is this
investigator's contention that the number of homosexual
or bisexual patients was probably underestimated, simply
44
because many of the gay patients were not recognizable
as such and may not have identified themselves as gay
to the physicians.
This
co~tention
will be justified in
the following sections.
Tables 9 through 12 P!esent crosstabulations of
Questions 1 and 2 with the knowledge, attitude and
clinical practice scores.
Chi square analysis of the
results showed no significant relationships between
knowledge, attitude and clinical practice scores and number of cases of either patients with possible gonorrhea
or syphilis, or numbers o.f those patients whom the
I
physicians believed to be homosexual or bisexual, with
one Axception.
This may mean that those physicians who
had seen few or no patients with possible gonorrhea or
syphilis,
~nd
had identified few or no gay male patients,
did not differ significantly in their attitudes toward
gay patients from those physicians who had seen many of
those types of patients.
Nor did their level of knowledge
differ with number of patients seen.
The important exception to these results is presented jn Table 12.
A crosstabulation of Question 2 by
the practice scores shows a significant
r~lationship
between the practice scores of the physicians and the
number of homosexual patients whom they identified. The
Pearson correlation coefficient for the relationship is
0.26, significant at the .OOf level.
While the correla-
i.
45
Table 9
• I
CROSSTABULATION OF QUESTION 2* BY KNOWLEDGE
Knowledge
Response
poor
fair
good
Questicn 2
n
n
n
none
8
32
19
59
1 to 5
14
44
40
98
5 to 10
1
3
6
10
10 to 30
0
5
4
9
more than 30
0
2
1
3
23
86
70
179
total
x2
total
not significant
*Question 2: Of those men who had gonorrhea or syphilis
.or their symptoms approximately how many did you
believe t6 be homosexual or bisexual?
-
·..-..:... ~~-·~·•L•-· ---••
-~
46
Table 10
CROSS TABULATION OF QUESTION 2* BY ATTITUDE
Attitule
Response
negative
neutral
positive
n
n
n
none
22
20
17
59
1 to· 5
28
29
41
98
5 to 10
3
2
5
10
10 to 30
1
2
6
9
more than 30
1
0
2
3
55
53
71
179
Question 2
total
x2
total
not significant
*Question 2: Of those men who had gonorrhea or syphilis
or their symptoms approximately how many did you
believe to be homosexual or bisexual?
47
Table 11
CROSSTABULATION OF QUESTION 1* BY PRACTICE
Practice
poor
Response
fair
good
total
Question 1
n
n
n
none
0
0
1
1
1 to 10
18
18
17
53
10 to 30
8
16
11
35
30 to 50
5
4
3
9
more than 50
2
4
3
a..-
33
42
35
110
total
x2
not significant
*Question 1: Approximately how many cases of suspected
gonorrhea and syphilis in all males did you see
last year'?
48
Table 12
CROSSTABULATION OF QUESTION 2*
BY PRACTICE
Practice
poor
Response
fair
good
n
n
n
none
12
6
2
20
1 to 5
16
27
24
67
Question 2
i
1
total
5 to 10
2
4
3
9
10 to 30 or
more
2
4
5
11
32
41
34
107
total
2
x , 8 df = 15.47,
PL
o.o5
*Question 2: Of those men who had gonorrhea or syphilis
or their symptoms approximately how many did you
believe to be homosexual or bisexual?
49
tion coefficient
is small, it does indicate a positive
direction of relationship.
Therefore it appears that
the clinical practice score was higher for those physicians who had seen more gay or bisexual male patients.
While increased experience with these patients does not
imply a change in the sample physicians• knowledge or
attitude toward the gay male patients, it may positively
affect their behavior in actually detecting and treating
gonorrhea and syphilis in that population.
Identifying the Homosexual Patient
Results .•
In Table 3 it can be
22.7 per cent indicated that
told them.
seen that, of 127 physicians,
11
many 11 of their patients
Sixty three per cent indicated that few or
none of their patients told the physicians they were
homosexual.
79.5 per cent of the physicians identified
either few or none of their patients as gay by
thos~
patients presenting with rectal or pharyngeal symptoms,
while only twenty per cent had patients whom they did
identify this way.
Approximately 79 per cent of the
·physicians indicated that they saw few or no patients
whom them identified as gay
characteristics.
becaus~
of effeminate
Eighty four per cent of the physicians
saw few or no patients whom they identified as homosexual
because they were sent in by a male contact.
Eighty one
Table 13
RESPONSES TO QUESTION 3:
Question No. 3:
Response
FREQUENCIES AND PERCENTAGES.
What. indications were there that these. men might be homosexual or
bisexual?
They told you
They had rectal
or pharyngeal
symptoms
adj.freq. f
(pet)
f
adj. freq.
(pet)
They had
"effeminate"
characteristics
f
They were sent
in by a male
contact
adj. freq.
(pet)
f
adj. freq.
(pet)
few
47
36.7
46
36.2
42
33.1
31
24.4
some
18
1~.1
21
16.5
·21
16.5
12
9.4
many
28
22.7
5
3.9
6
4.7
3
2.4
L
:
,,
[1
none
26.2
100%
_ll
127
missing cases:
..22
127
43.3
100%
2ft
127
45.7
100%
_!li
127
63.8
100%
:.
81
V1
0
~
!.
?
51
physicians did not answer the question.
Discussion.
The results of this table leave one wondering how
these physicians identified the patients as homosexual,
other than the small number whose patients told them.
Some of the physicians ask their patients about homosexual
contacts, as will be discussed.in the following section.
But many do not.
The literature contains many examples
of physicians discussing their homosexual patients without
stating how they were able to identify the patients as
such.
{44:136) (59:199)
(&9:~6)
I
Typical is the statement
by Pariser and Marino in their article "Gonorrhea -Frequently Unrecognized Reservoirs:"
"Over a 12 montn
period all males suspected of homosexual activity were
exami:1ed •
o
o
o
II
(59! 199)
(my emphasis)
Identification
of the patient as homosexual is obviously an important
prelude to treating the male patient for rectal or
pharyngea.i gonorrhea unless the physician wishes to do
rectal or pharyngeal examinations
with possible
gonorrh~a
~n
every male patient
or syphilis.
Asking Patients about Homosexual Contacts
Results.
Table 14 summarizes the responses to Question 4
on the questionnaire.
Twenty-one per cent of the
physicians always ask their male patients with gonorrhea
i.
52
Table 14
RESPONSES TO QUESTION 4:
Question No. 4:
FREQUF.NCIES AND PERCENTAGES
How often do you ask your male patients
who request treatment for possible
syphilis or gonorrhea if they have had
a homosexual contact?
Response
abse.lute
frequency
adjusted
frequency
(per cent)
cumulative
frequency
(per cent)
always
39
21.9
21.9
sometimes
58
32.6
54.5
rarely
48
27.0
81.5
_li
178
18.5
100%
100.0
100%
never
missing cases:
30
!'
I!
Table 15
RESPONSES TO QUESTION 6:
Question No. 6:
FREQUENCIES AND PERCENTAGES
If a patient whom you know to be a married man asks you for treatment
of gonorrhea, (a) do you ask him about sexual relations outside of
his marriage?
(b) does your inquiry include questions about
homosexual contacts?
(c) do you inspect and/or culture his throat
and rectum for signs of infection?
Response
(b)
(a)
f
adj.
freq.%
f
adj.
freq.%
(c)
f
adj.
freq.%
'!
yes
no
sometimes
I
172
8~.6
42
22.3
41
22.3
9
4.7
91
48.4
82
44.6
_9
192
_L..1
_2.2.
188
29.3
100%
__§]_
100%
33.2
100%
missing
cases: 16
missing
cases: 20
184
missing
cases:24
U1
w
---
--------------~-----------
54
Table 16
CROSS TABULATION OF QUESTION 3a* BY QUESTION 4**
Question 3a
never
rarel:r
sometimes
always
n
n
n
n
few
11
9
16
9
45
some
0
3
9
6
18
many
2
3
10
13
29
none
6
15
9
4
34
19
31
44
32
126
Response
Question 4
total
x2, 9 df = 23.89,
*
total
PL . 005
Question 3a: What indications W3re there that these
men might be homosexual or bisexual? They told you.
** Question 4 : How often do you ask your male patients
who request treatment for possible syphilis or
gonorrhea if they have had a homosexual contact?
55
Table 17
CROSSTABULATION OF QUESTION 4* BY QUESTION 6b**
Question 6b
Response
no
Question 4
n
n
n
never
30
2
0
32
rarely
35
j13
0
48
sometimes
14
29
11
54
4
9
24
37
83
53
35
171
always
total
x2 ,·
sometimes
6df = 103.97,
PL
yes
total
0.001
*Question 4:
How often do you ask your male patients who
treatment for possible syphilis or gonorrhea
if they have had a homosexual contact?
reques~
**Question 6b: If a patient whom you know to be a married
. man asks you for treatment of gonorrhea, does your
inquiry include questions about homosexual contacts?
56
or syphilis if they have had a homosexual contact;
32.6 per cent sometimes ask, and 45.5 per cent rarely
or never ask this question.
Table 15, section b in-
dicates that 22.3 per cent of the physicians always
ask married men who request treatment for gonorrhea if
they have had a homosexual contact;
29.3 per cent some-
times ask this question, and 48.4 per cent do not ask
their
married patients about homosexual contacts.
Table 16 demonstrates an association between those
physicians who had many pat·ients who told them about
their homosexuality, and thosA physicians who ask their
patients about homosexual contacts.
The correlation
coefficient is 0.67, significant at the .001 level.
Table 17 indicates that those physicians who ask their
patients about homosexual contacts are probably the
same physicians who ask the same question of marr.ied men.
(The Pearson Correlation Coefficient is 0.68, significant
at the .001 level.
Discussion.
An average of fifty-two per cent of the physicians
stated that they asked their patients, married·and unnarried, who requested treatment for gonorrhea or syphilis,
about homosexual contacts.
Approximately forty-eight
par cent did not.
In a study conducted by the American Medical
Association's Center for Health Services, Research and
---
--~-
---.-, = - - - - o - - - - - : - . c -' _ c - - -
o---,.-.
::-o-
'
---=--v--=-·=-=,----_-,---_~=-··-.-.o-~~-.--~~~·-----'=-•··~·
57
Development (reported by Golin)", in 1978, 91.7 per cent
of the general and family practitioners and 81 per cent
of the internists said that they included questions about
sexual practices when taking histories.
(24:2)
Indeed,
in this present study, 89.6 per cent of the physicians
asked married men about sexual relations outside of the
marriage.
When it comes to ask]ng about homosexual
contacts, however, Golin states "The physician may
feel embarassed to ask the male patient questions about
the gender· • • • of sexual relations."
(64:2)
This
may be especially true when tre patient is married.
Some physicians may make the assumption that a
married man is by definition not a homosexual.
responds:
Jefferiss
"One • • • frequently sees men, often married,
who have normal
s~xual
relations with women but enjoy
being 'passive' with their men friends."
(34:741)
Dunlop, Lamb and King found that thirty-eight per cent of
'
the homosexual men they examined admitted to having
heterosexual intercourse at some time.
(16:128)
It appears, therefore, that nearly half of the
physicians in the sample may have missed diagnosing
gonorrhea or syphilis in those gay or bisexual male
patients who did not tell the physicians about their
homosexual activities.
58
Table 18
RESPONSES TO QUESTION 8:
Question No. 8:
pharyngeal
gonorrhea
frequency
no
undecided
AND
PERCENTAGES
In your professional op1n1on are
pharyngeal and rectal gonorrhea
frequently asymptomatic?
Response
yes
FRE::2UENCIES
adj. freq.
per cent.
rectal
gonorrhea
frequency
adj.freq.
per cent
103
55.1
115
65.7
45
24.1
21
12.0
_l2_
20.8
100%
_l2_
22.3
100%
187
. missing cases:
21
175
missing cases:
33
59
Asymptoma·tic Infection
Results.
Table 18 summarizes the responses to Question 8:
11
In your professional opinion are pharyngeal and rectal
gonorrhea frequently asymptomatic?"
Regarding pharyngeal
gonorrhea, 55.1 per cent stated that it is frequently
asymptomatic,
24.1 per cent disagreed and 20.1 per cent
were undecided.
Concerning rectal gonorrhea, 65.7 per
cent iudicated that.it is frequently asymptomatic, twelve
per cent disagreed and 22.3 per cent were undecided.
Seven physicians added the written comment that they had
never really thought about the question before.
Discussion.
Rectal gonorrhea has been reported in various
studies to be asymptomatic in
~nywhere
from 48 per
cent of cases (16:128) to 66 per cent of cases.
(50:51)
The patients in thes.e studies were homosexual men who
either c&me to the clinics for rout.ine checkups, without
any symptoms, came for treatment of a urethral infection,
or were examined in a bathouse seetir.g (Merino and
Richard's study.)
(SO)
Pharyngeal gonorrhea in homosexual men has also
been found to be frequently nsymptomatic
~56:470)
(50:51)
{16:126) but the percentages of asymptomatic infection
detected vary greatly with the settings.
Dunlop, Lamb
and Kine; compared studies done in Britain and concluded
60
that "gonococcal infection of the pharynx is not commonly
diagnosed in the United Kingdom."
(16:129)
These two questions (are rectal and pharyngeal
gonorrhea frequently asymptomatic?) account for one half
of the "knowledge saore" assigned physicians' responses.
If a physician is not aware that the gay male patient
could have asymptomatic rectal or pharyngeal gonorrhea
(or a painless syphlitic
ch~ncre
in one of those areas)
he may not examine or culture the area unless asked
to do so by the patient.
This knowledge, therefore, is
crucial to the physician who wishes to detect all cases
of gonorrhea and syphilis which may pass through his
office.
Three-site Examination
a~d
Culturing
Results.
Tables 15 {page 53) and 19 (page 61) indicate the
following:
regarding patients with possible gonorrhea
or syphilis whvm the physicians believed to be homosexual or bisexual:
87.5 per cent of the physicians state
that they always culture the urethra;
42.1 per cent say
they always culture the pharynx and 49.3 per
always culture the rectum.
~ent
say they
Aoproximately thirty-eight
per cent of the physicians sometimes culture the pho.rynx,
and twenty per cent state that they never do.
Of the
physicians who responded, 38.5 per cent indicate that
Table 19
RESPONSES TO QUESTION 5:
Question No. 5:
Response
always
sometimes
never
f
FREQUENCIES AND PERCENTAGES
For those men whom you believed to be homosexual or bisexual,
what sites did you examine and/or culture for gonorrhea
or syphilis'?
cum.
adj.
freq.% freq. %:,
f
adj.
cum.
freq.% freq.%
f
adj.
cum.
freq.% freq.%
133
87.5
87.5
59
42.1
42.1
73
49.3
49.3
15
9.9
97.4
53
37.9
80.0
57
38.5
87.8
_3
152
_bQ
100.0
100%
~
20.0
100%
100.0
100%
_li
100%
missing cases: 56
140
missing cases: 68
148
i.
12.2 100.0
100%. 100%
missing cases: 60
~
~
62
that they sometimes culture the· rectum, and 12.2 per cent
say they never do so.
Sixty physicians did not answer
the question on rectal gonorrhea.
For married men
·requesting treatment for gonorrhea, 22.3 per r::ent of the
physicians claim they inspect and/or culture the throat
and rectum, 33.2 per cent say they sometimes do so,
and 44.6 per cent say they do not examine and/or culture
those sites in married men.
Table 20 compares the physicians' responses to
Question 3b (the physician suspected that the patient
was homosexual or bisexual because of rectal or pharyngeal
symptoms) to those of Question 5 (how often do they
examine and/or culture the rectum of patients believed
to be homosexual or bisexual.)
Chi square analysis
indicated that thAre is no relationship between the
respondents to the two questions.
Therefore those
physicians who recognized that some patients were gay
because of rectal and pharyngeal symptoms are not
necessarily th.e same physicians who always do rectal
examinations on pa·tients they believe to be gay.
However, the number of physicians who identified gay
patients by symptoms was quite small so the statistics
may not be reliable.
Table 21 examines the relationship between the
response to Question 8 (is pharyngeal gonorrhea frequently asymptomatic) and Question 5 (does the physician
--:-...
----,'-
_--
-~--·-·.-: .. -
,-
63
Table 20
CROSSTABULATION OF QUESTION 3b* BY QUESTION 5**
Question 5
Response
'!lever
sometimes
always
Question 3b
n
n
n
few
3
23
19
45
some
0
6
15
21
many
0
3
2
5
none
9
18
22
49
12
50
58
120
total
total
x2 - not significant
*
Question 3b: What indications were there that these men
might be homosexual? They had rectal or pharyngeal
symptoms.
**Question 5:
For those men whom you believed to be
homosexual or bisex-ual, what sites did you examine
and/or culture for gonorrhea or syphilis?: rectal.
64
Table 21
-CROSSTABULATION OF QUESTION 8* by Question 5**
Question 5
Response
never
sometimes
Question 8
n
n
n
no
7
114
I
12
13
undecided
5
9
8
22
16
29
37
82
28
52
57
137
yeo
total
always
total
2
'
X not significant
*
Question 8: In your professional opinion is pharyngeal
gonorrhea frequently asymptomatic?
** Question 5: For those men whom you believed to be
homosexual or bisexual, what sites did you examine
and or culture for gonorrhea or syphils? pharyngeal.
65
examine or culture the pharynx of those patients he
suspects to be homosexual or bisexual.)
Table 22 examines
the relationship between knowledge of asymptomatic
rectal gonorrhea and the number of physicians who examine
the rectum in patients whom the physician believes to
be homosexual.
The results of both tables indicate no
association between awareness of asymptomatic disease and
the practice of culturing the throat or rectum.
The data in Table 23 shows that those physicians
in the sample who asked if there had been a homosexual
contact are probably t,he same physicians \vho frequently
(always or sometimes) culture the throat and rectum
of married patients who request treatment for gonorrhea.
Table 24 demonstrates a significant association
between the frequency with which the sample physicians
examine the pharynx and the rectum.
(The correlation
coefficient for the responses to these two questions is
0.71, significant at the .001 level.)
Discussion.
The most apparent conclusion to be drawn from
these results is that, in the sample population, knowledge
that rectal and pharyngeal gonorrhea are frequently
asymptomatic, was not carried out in practice by
consistent examination or cult11re of the pharynx or
rectum of gay patients with possible gonorrhea.
This
could imply that some of the sample physicians do not know
66
Table 22
. CROSSTABULATION OF QUESTION 5* BY QUESTION 8**
Question 5
Responc;e
never
sometimes
Question 8
n
n
n
no
1
4
11
"18
undecided
4
10
11
25
11
38
46
95
16
52
68
136
yes
total
x2
*
**
always
total
not significant
Question 5: For those men whow you believed to be
homosexual or bisexual, what .sites did you
examine and/or culture for gono~rhea or syphilis?
rectal.
Question 8:
In your professional opinion is rectal
gonorrhea frequently asymptomatic?
67
Table 23
CROSSTABULATION OF QUESTION 4* BY QUESTION 6c**
Question 6c
Response
no
Question 4
never
sometimes
yes
n
n
n
23
6
3
32
13
6
47
total
I
1
rarely
28
sometimes
15
27
10
52
8
12
16
36
74
58
35
167
always
total
x2 ~ 6 df = 35.31,
*
PL
.001
Question 4: How often do you ask your male patients
who request treatment for possible syphilis or
gonorrhea if they have had a homosexual contact?
** Question 6c: If a patient whom you know to be a married
man asks yo~ for treatment of gonorrhea, do you
inspect and/or culture his throat and rectum for
signs of infection?
68
Table 24
CROSSTABULATION OF QUESTION Sa* BY QUESTION Sb**
Question Sb (rectal)
never
sometimes
always
n
n
n
t.otal
15
8
5
28.
sometimes
2
42
8
52
always
1
4
53
58
18
54
66
138
Response
Question Sa
(pharyngeal}
never
total
x2, 4 df = 123.27,
PL • 001
*
Question Sa: For those men whom you believed to be
homosexual or bisexuaL what sites did you examine
and/or culture for gonorrhea or syphilis? pharyngeal
**
Question Sb: For those men whom you believed to be
homosexual or bisexual, what sites did you examine
and/or culture for gonorrhea· or syphilis·? rectc-_1
69
that homosexual men frequently engage in oral and
anal sex.
However, this is doubtful, because some of
the very common pejorative terms for male homosexual
(such as buggerer) which are used in our society refer
to the act of anal sex.
Therefore, it appears that some as yet unexplained
factors induce some physicians to do rectal and pharyngeal
examinations even if they are not aware of the possibility
of asymptomatic disease.
Furthermore, some factor must
explain those physicians who know gonorrhea can be asymptomatic but fail to examine the rectum or pharynx.
In
the previously mentioned report from the Center for
Health Services, Research and Development poll, it is
stated:
Less than half {46%) of the 282 physicians
participating in the Impact poll say they perform
anoscopic examinations of male patients presenting
with anal gonorrhea. More than one third (35%)
say that they do not, and 19% did not answer this
question. More than two-thirds of the doctors
{67.1%) however, say they do appropriately Cillture
the male homosexual patients when they have obtained
information about his sexual practices; 19.8 say
they do not, and 31.1 did not reply... {24: 2)
11
Pauly and Goldstein cited a study in which "36
per cent of medical students thought that their peers
might omit the rectal or genital examination of a Lhomosexua!/ patient because they were uncomfortable at the
prospect of examining these organs.
{60:31)
In a recent
issue of Time magazine, during a discussion of Masters
and Johnson's recent study on
homosexuali~y,
the following
70
was s ta t.ed:
"In the past • • • some doctors refused to give
them Lhom0sexual male§/ rectal examinations for
fear of causing arousal, a concern that has
never been shown by gynecologists conducting
vaginal examinations." (46:78)
This might explain the failure of some physicians
to do rectal examinations;
it does not account for
failure to do a pharyngeal examination and culture on
those patients with possible gonorrhea whom the physician
knows or suspects to be homosexual.
Results in Tables 17 (page 55), 20 (page 63},
23 (page 67) and 24 (page 68) indicate
that those
physicians who ask about homosexual contacts are probably
the same physicians who ask the question of married men,
(Pearson correlation coefficient for comparison of
Questions 4 and 6b is 0.67, significant at the .001
level) and who examine the ractum and pharynx of those
two categories of
~atients.
{The four tables also
indicate the internal consistency of the "clinical
practice" questions, as all practice questions are crosstabulQted in the four tables and all results show signi. ficant relationships.)
Regarding the uecessity of examining and culturing
the pharynx, Newnham states:
"It is stressed that all patients suspected
of suffering from venereal diseases should have
their throats swabbed as a routine.
Information
as to whether or not oral sex is practiced should
be obtained. (45:471)
71
Finally, Dunlop, Lamb and King-stress that "anorectal
tests are essential as a routine . • • for most homosexual
meTl because over 80 per cent of these men will have had
passive anorectal intercourse at some time."
(16:129)
Treatment of Rectal and Pharyngeal Gonorrhea
Results.
Table 25 summarizes the responses to Question 7:
of the 187 physicians who responded to this question,
81.8 per cent believed that the dosage of antibiotic
used for penile gonorrhea is sufficient for any rectal
or pharyngeal gonorrhea.
Approximately 11 per cent
disagree and 6.4 per cent feel that the dosage is "sometimes" sufficient.
Discussion.
While research is still being conducted to find
adequate dosages of antibiotic for successful cures of
gonorrheal pharyngitis and gonorrheal proctitis, it
bas been recognized for several years that these infections have high failure-to-cure rates with the standarc
dose of Ampicillin {3.5 million units of Ampicillin
plus 1.0 grams of probenicid.)
{11:23) (34:743) (40:340-6)
Pharyngeal gonorrhea has been found to be especially
resistant, even to spectinomycin.
Both the,1975 and
1977 Center for Disease Control (C.D.C.) recommendations
warned about the high failure rates in treatment of
72
Table 25
RESPONSES TO QUESTION 7:
Question No. 7:
.FREQUENCIES
AND
PERCENTAGES
If you treat a male for penile gonorrhea
do you believe that the dosage of antibiotic you use is sufficient to cure
any rectal or pharynge~l gonorrhea
that may also be present?
Response
absolute
frequency
adjusted
frequency
(per ·cent)
cumulative
frequency
(per cent)
yes
153
81.8
81.8
no
21
11.2
93.0
__u
_§_d
187
100%
100.0
100%
sometimes
missing
cas~s:
21
73
pharyngeal gonorrhea. ·
( 2 4) ( 26)
Anorectal infection has also been found to be
resistant to the standard dosa0e used for penile (urethral)
gonorrhea.
Jefferiss stated that:
"The rectal cases db not respond to penicillin
injections nearly as well and are best treated
by giving penicillin and probenecid as for urethral gonorrhea, followed by Ampicillin 250 mg.
four times a day by mouth for five days. A
possible reason for this poor response is that in
a rectal infection, some of the gonoccal pus
becomes caught up in the faeces and remains there
to reinfect the rectal tissue mucosa when the
antibiotic level falls below a bacteriostatic or
bacteriocidal level." (34:743)
Therefore, physicians who routinely treat any
cases of rectal or pharyngeal gonorrhe3. with the standard
3.5 million units of Ampicillin plus probenecid may be
unknowingly releasing, as cured, still infective patients
who have clinically silent gonorrhea because of inadequate
antibiotic treatment, which has suppressed symptoms but
not cured the disease.
(16)
There appears to be no correlation between the
sample physicians' level of knowledqe regarding adequate
antibiotic treatment and their level of clinical pract:i.ce.
as measured by the indicated parameters.
Attitudes Toward Gay Male Patients
Results.
Tables 26 through 29 summarize the attitudes of the
sample population of physicians ·toward male homosexual
74
Table 26
RESPONSES TO QUESTION 9:
Question No. 9:
AND
PERCENTAGES
Would you rather not have openly
homosexual men as regular patients?
Response
absolute
frequency
I
would rather not
I
don't mind
undecided
12
adjusted
frequency
(per cent)
60
30. 6'
127
64.8
___2
_L_§_
100%
198
missing cases:
FREQUENCIES
75
Table 27
RESPONSES TO QUESTION 10:
Question No, 10:
FREQUENCIES
AND
PERCENTAGES
Will you accept the referral of a
homosexual for treatment?
Response
absolute
frequency
adjusted
frequency
:(per cent)
yes
126
66.7
no
52
27.5
_ll
~
undecided
189
missing cases:
19
100%
•
I
I
Table 28
RESPONSES TO QUESTION 11:
Question 11:
Response
yes
no
FREQUENCIES AND PERCENTAGES
Do you feel that homosexuality in men is (a) a social threat;
\b) an illness;
(c) a valid alternative to heterosexuality;
(d) immoral;
(e) an inb0rn trait of some individuals?
threat
illness
alternative
immoral
trait
f
adj.
freq.%
f
adj.
freq.%
f
adj.
freq.%
f
adj.
freq.%
f
adj.
freq.%
48
27.1
76
42.2
50
29.8
40
23.7
63
35.8
111
62.7
79
42.8
79
47.0
109
64.5
77
43.7
I_?
i
I'
I
I
undecided
_1,]_
177
10.2
100%
missing
cases: 31
_n
180
15.0
100%
missing
cases: 30
_]2
168
23.2
100%
missing
cases: 40
~
169
11.8
100%
missing
cases: 39
__].§.
176
20.5
100%
missing
cases: 32
-...)
0\
'
~~,
~--
~-------
---
77
patients.
Table 25 refers to openly homosexual patients:
patients who make it quite obvious, either by effeminate
gesture&, conversation, buttons ("gay power") or other
signs that they are homosexualc
Thirty-six per cent of
the physicians stated that they would rather not have
those men as regular pat.ients;
64.8 per cent stated
that they don't mind, and 4.6 per cent were undecided.
Table 27 shows that 66.7 per cent of the physicians
will accept the referral of a homosexual for treatment.
Table 28 summarizes the ways in which the physicians view
homosexuality in men.
Twen~y-seven
per cent feel that
it is a 3ocial threat, while 62.7 do not. Approximately
43 per cent do not feel that homosexuality in men is
an illness, and the same amount think that it is.
Fifteen per cent are undecided.
Approximately 30 per
cent agree that homosexuality is a valid alternative to
heterosexua'Iity, while forty-seven per cent do not agree,
and 23.2 per cent are
unde~ided.
About two-thirds
of the physicians feel that homosexuality in males is
not immoral.
43.7 pe::- cent do not feel that it is an
inborn trait.
Table 29 summarizes the physicians' own feelings
when male homosexual patients ask them for treatment.
Few of the physicians indicate that they feel curiosity
(7.9 per cent), discomfort (7.4 per cent), dislike (6.3
per cent) or pity (10.1 per cent.)
However, 54.5 per
Table 29
RESPONSES TO QUESTION 12:
Question No. 12:
Response
FREQUENCIES AND PERCENTAGES
What are your own feelings when a male homosexual patient asks
you for treatment?
(mark as many as are applicable)
curiosity
discomfort
f
f
adj.
freq.%
adj.
freq.%
neutral
acceptance
pity
adj.
freq.%
f
adj.
freq.%
f
adj.
freq.%
f
adj.
freq.%
dislike
f
--yes
15
7.9
14
7.4
12
6.3
114
60.3
85
45.0
19
10.1
no
174
189
92.1
100%
175
189
92.6
100%
177
189
93.7
100%
__12.
39.2
100%
104
189
54.5
100%
170
189
89.9
100%
'missing cases:
189
19
...,J
00
79
cent state that they do not feel "acceptance" of the
patient while 45 per cent state that they do.
Approxi-
mately sixty per cent state that their feelings are
neutral~
not.
while 39.2 -per cenc: indicate that theirs are
Table 30 compares Question 9 (rather not have
homosexual patients} with Question lla (social threat).
There is a significant
relationship~
and a correlation
coefficient of .30 indicates that it is positive.
This
means that those sampled physicians who agreed that male
homosexuality is a social threat would rather not have
openly homosexual patients.
Table 31 compares Question 9 ("would you rather
not have openly homosexual patients?") with Question
llc ("do you feel that homosexuality in males is a
valid alternative to heterosexuality?"). , There is a
significant relationship.
It is interesting to note
that the largest number of physicians (44)
disagr~ed
that homosexuality in men is a valld alternative to.
heterosexuality, but indicated that they didn't mind
having openly homosexual patients.
Further research
would be needed to explain these rather contradictory
findings.
Discussion.
The report from the Center for Health Services,
Research and Development found that "Three out of five
physicians (61%)say 'It doesnt bother me at all.' About
80
Table 30
CROSSTABULATION OF QUESTION 9* BY QUESTION lla**
Question lla
Response
undecided
yes
Qllestion 9
n
n
n
total
undecided
3
3
3
9
rather not
7
!26
17
50
don't mind
8
17
88
113
18
46
108
172
total
x2 I
4 df = 36 • 131
l
PL
no
.001
*
Question 9: Would you rather not have openly homosexual
men as regular patients?
**
Question lla: Do you feel that homosexuality in men
is a social threat?
81
Table 31
CROSSTABULATION OF QUESTION 9* BY QUESTION 11c**
Question 11c
undecided
yes
Question 9
n
n
n
total
undeL!ided
5
4
0
9
rather not
6
34
5
45
don't mind
24
39
44
108
total
36
77
49
162
Response
x 2 , 4 df
*
= 28.66, p
no
L .001
Question 9: Would you rather not have openly homosexual men as regular patients?
** Question 11c: Do you feel that homosexuality in men
is a valid alternative to heterosexuality?
82
one in three (35.5%) says 'I'm sometimes uncomfortable.'
Only 1.8% says ,'I'm often uncomfortable' and 3.7% did
not reply." {24: 2)
Los Angeles has a more concentrated population of
homosexuals than the country as a whole (from which the
Center's study was taken.)
Increased contact with
homosexuals may account for the finding that fewer
physicians in this present study experience discomfort
with homosexual patients than those in the Center's study.
Probably the most important study dealing with
physician's attitudes toward homosexuality was Pauly
l.
and Goldstein's study of physicians in Oregon.
In the
quesr.ionnaire, the physicians were asked if their
attitudes about male homosexuals could adversely affect
their medical treatment of such patients.
They found
that
"Physicians personally acknowledge fewer
negative attitudes toward their homosexual patients
than they attribute to ·~ost physicians.'
••• It is ••• quite likely t.hat physicians find
it diffieult to acknowledge negative attitudes
toward any patient, including a homosexual one,
as indication of less than a professional stance.
It is probable that the attitude of physicians
are more negative than those personally acknowledged
by the respondents and more towards that which is
attributed to 'most physicians.'" (60:37)
83
The Importance of Unders t·anding
the Gay Male Life Style
Result§..
It is presented in Table 32 that 83.4 per cent of
the physicians believe it is important for a physician
to have some understanding of the
~ale
homosexual life
style and sexual activities in order to adequately
diagnose_ and treat that type of patient for syphilis and
gonorrhea.
Nine point three disagree, and 7.3 per cent
state that it is "sometimes" important.
In Table 33
it can be seen that there is no relationship between the
attitude scores of the respondent physicians and their
agreement or disagreement with the statement in Question
13.
In table 34, however, a highly significant relation-
ship was demonstrated between the clinical practice
scores of the physicians and their agreement or disagreement with the statement.
The Pearson correlation
coefficient is 0.35, significant at the .001 level.
While not a high correlation, it doas indicate that there
may be a positive correlation between the two.
That is,
the higher the physicians• clinical practice scores are,
the more likely they are to agree with the statement
about importance of the gay male life style.
Discussion.
Question 13 essentially sums up the preceding
sections of the questionnaire.
The question asks:
84
Table 32
RESPONSES TO QUESTION 13:
FREQUENCIES
AND
PERCENTAGES
Question No. 13:
Do you believe that it is important
for a physician to have some
understanding of the male homosexual
life style and sexual activities
in order .to adequately diagnose and
treat him for syphilis and gonorrhea?
Response
absolute
frequency
adjusted
frequency
(per cent)
161
83.4
18
9.3
__!.!
..L.l.
yes
no
sometimes
193
missing cases:
15
100%
85
Table 33
CROSSTABULATION OF QUESTION 13* BY ATTITUDE
Attitude
Response
negative
neutral
positive
Question 13
n
n
n
total
no
6
5
7
18
sometimes
4
5
5
14
47
48
66
161
7
58
78
193
yes
· total
x2
*
not significant
Question 13:
Do you believe that i t is important for a
to have some understanding of the male
homosexual life style and sexual activities in order
to adequately diagnose and treat him for syphilis
and gonorrhea?
~hysician
r .
86
Table 34
CROSSTABULATION OF QUESTION 13* BY PRACTICE
Practice
Response
poor
fair
good
Question 13
n
n
n
tot::tl
no
6
4
0
8
sometimes
5
3
1
9
21
35
35
91
32
40
36
108
yes
total
x2, 4 .df = 14.03, pf. • 005
'
~··
*
I
Question 13: Do you believe that it is important for
a physician to have some understanding of the
male homosexual life style and sexual activities
in order to adequately diagnose and treat him for
syphilis and gonorrhea?
87
"Do you believe that it important for a physician to
have some understanding of the male homosexual life
style and sexual activities in oroer to adequately
diagnose and treat him for syphilis and gonorrhea?
The majority of the literature which this investigator reviewed indicates that understanding of the
gay male life style is required for adequate detection
and treatment of gonorrhea and syphilis in that population.
The majority of the respondents to this questionnaire
agree.
The results of this present survey have indicated,
however, that among the
sam~le
population, knowledge
of manifestations of qouorrhea.and syphilis (i.e.
asymptomatic disease) does not necessarily mean adequate
clinical practice in diagnosing the diseases.
In Table 34 a definite relationship can be noted
between levels of adequacy of clinical practice and
the responses to Question 13.
As was mentioned,
the
positive correlation coefficient indicates that those
physicians who are more effective in diagnosing and
treating gonorrhea and syphilis in gay men (according
to their own statements) are more aware of the importance
of understanding the life styles of gay patients.
It is this investigator's contention, therefore,
that a physician may know that male homosexuals are
frequently promiscuous and often participate in rectal
sex;
if, however, that physician does not know of the
88
frequent asymptomatic manifestations of gonorrhea and
syphilis in that population, there would be nothing to
raise his clinical index of suspicion on patients without
symptoms, and he would consequently miss many cases of
those diseases in his gay male patients.
Furthermore,
if the physician knows both of the gay male life style
and of the asymptomatic manifestation of the diseases
in these patients, he will still fail to diagnose many
cases of gonorrhea unless he does three-site testing,
including anoscopy, on all his gay male patients on a
routine basis.
(If he routinely does V.D.R.L. 's or
other blood tests for detection of syphilis, as many
physicians do, then few cases of syphilis will pass
unnoticed by the physician.)
Medical School Training Regarding Homosexuality
.Kesults.
Table 35 summarizes the amount of information the
physicians received regarding male homosexuality while
in medical school.
they received none;
Over half (54.5 per cent) state that
about forty-three per cent received
"a little" or "some", and only two per cent of the
physicians indicated that they received "a lot" of
information in medical school on the subject.
square analysis revealed that there was no
Chi
signific~nt
relationship between amount of medical school training
89
Table 35
RESPONiJES TO QUESTION 14:
Question No. 14:
FREQUENCIES
AND
PERCENTAGES
When you attended medical school how
much information regarding homosexual
life styles and sexual activities was
imparted to you?
Responses
absolute
frequency
none
110
adjusted
cumulative
frequency frequency
(per cent} (per cent}
54.5
54.5
a little
64
31.7.
86.1
some
24
11.9
98.0
____!
~
100.0
100%
a let
202
missing cases:
6
100%
90
and knowledge, attitude and practice scores.
null hypothesis number 3 is accepted.:
Therefore,
there is no
relationship between the amount of information
regardin~
homosexuality which the physicians received in medical
school, and the attitude, knowledge and clinical practice
scores of the physicians.
Discussion.
It is evident that, among this sample population
of physicians, those physicians who received "a lot" of
information do not differ in their attitudes, knowledge
cr clinical practice scores from those physicians who
received none.
However, it must be pointed out that
there were only four physicians who received "a lot"
of information, and 110 physicians who received none.
The number of physicians who received "a lGt" of
training is too small for any definite conclusion regarding relation-ship to attitude, knowledge or clinical
practice.
In the report from the Center for Health Services,
Research and Development poll, it was reported that 84.1
per cent of the respondent physicians felt that they did
not receive adequate training in sexuality and homosexuality.
(24:2)
Sandholzer also states:
"Because of gaps in training about S.T.D.,
indications are that many physicians miss diagnoses
of these p~oblems, particularly in homosexual
male patients, because they don't always ask the
right questions about sexual practices, and
consequently aon't perform the tests-that would
91
corroborate the presence of disease."
(64:2)
There were so few respondents in this present
study who had been given "a lot" of information in
medical school, that we really don't know how a wellplanned, thorough training program about V.D. in
homosexual men might affect the attitude or practice
scores.
It is this writer's contention that thorough
training, with the physicians subsequently feeling
comfortably conversant in the subject, would probably
lead to a more accepting attitude, through familiarity.
Feeling more comfortable wit;.h the subject of gay V.D.
!
might, in turn, place the physicians in a position where
they would focus their attention away from the possibly
ernbarrasing aspects of the situation and onto ways in
which they could do a better job of diagnosing and
treating the dise·ases in gay male patients.
Certainly
the more progressive attitudes appearing in this latter
part of tl .. e 1970's should also have an effect on
graduating medical students, and perhaps accomplish
more
~han
a thorough training program in medical school
might do.
Age of Respondents
Results.
Table 36 summarizes the respondent physicians'
ages.
As can be seen, the age
~urve
is essentially a
92
Table 36
RESPONfES TO QUESTION 16:
Question No. 16:
FREQUENCIES AND PERCENTAGES
What is your age?
Response
absolute
frequency
adjusted
cumulative
frequency frequency
(per cent)
(per cent)
30 to 39
26
12.9
12.9
40 to 49
42
20.9
33.8
50 to 59
70
34.8
68.8·
60 to 69
48
23.9
92.5
_Jd
_L2
201
100%
100.0
100%
70 or more
missing cases!
7
93
normal curve, with the majority of ·the physicians
(seventy-nine per cent) between the ages of forty
and sixty-nine.
Tables 37 through 39 compare the
physicians' ages with their attitude, knowledge and
clinical practice scores.
The relationship between
clinical practice scores and age is not found to be
significant in this population.
However, the relation-
ship between age and attitude is highly in this population.
Pearson correlation coefficient of the relationship is
-0.30, significant at the .001 level.While the correlation coefficient is quite smaJl, the fact th3.t it is
negative may indicate tbat the older a physician is,
the less likely he is to have a positive attitude
toward gay male patients (referring to the physicians
in the survey).
A significant relationship by chi
square was found to exist between age and the knowledge
score of the physicians.
However, the correlation
coefficient was not significant, indicating that no
direction in the relationship can be pinpointed.
There-
fore, null hypothesis number 2 is rejected on the counts
of attitude and knowledge relationships to age, and
accepted on count of the practice scores' relationship
to age of the respondent physicians.
Discussion.
Pauly and Goldstein found that "recent gradua,tes
(since 1960) claim more comfort in treating homosexuals
94
Table 37
CROSSTABULATION OF QUESTION 16 (AGE) BY ATTITUDE
Attitude
negative
Response
neutral
positive
Question 16
n
n
n
30 to 39
2
8
16
26
40 to 49
7
:19
16
42
50 to 50
22
19
29
70
60 to 69
24
9
15
48
9
3
3
15
64
58
79
201
70 or more
total
x 2 , 8 df = 28.21,
PL
.001
total
95
Table 38
CROSSTABULATION OF QUESTION 16 (AGE) BY KNOWLEDGE
Knowledge
poor
Response
fair
good
Question 16
n
n
n
30 to 39
6
113
7
26
40 to 49
10
15
17
42
total
50 to 59
2·
40
28
70
60 to 69
7
22
19
48
70 or more
1
11
3
. 15
26
101
74
201
total
x 2 , 8 df
=
18.45,
PL
.05
96
Table 39
CROSSTABULATION OF QUESTION 16 (AGE) BY PRACTICE
Practi~e
Response
poor
fair
good
Question 16
n
h
n
30 to 39
5
6
7
18
40 to 49
8
9
7
24
50 to 59
14
15
11
40
60 to 69
3
9
10
22
70 or more
2
1
1
4
32
40
36
108
total
x2
not significant
total
97
than their predecessors, and they also attribute moLe
negative attitudes-to 'most physicians' in this regard ...
(60:44)
If indeed the age-attitude correlation in true
for the general population of physicians, and if medical
schools are beginning to present increasingly sophisticated classes on sexuality, then we can at least hope
that the number of cases of rectal and pharyngeal
gonorrhea and syphilis which arc diagnosed and treated
by pLivate physicians will correspondingly increase as
mere physicians graduate from medical
school~
Sex of Respondents
Results.
In Table 40 the frequencies for sex of respondents
are given.
Of the 208 respondents, only two indicated
that they were female.
san~le
This was much too small of a
for any statistical test using sex as the depen-
dent variable-- to be reliable, so no correlational
tests were done.
Approxiamtely ten per cent of the
physicians to whom questionnaires were cent had first
names traditionally used by \•!omen.
It may be that
very few gay male patients have women physicians as
their private physic.:ians.
Or there may be some unknown
factor influencing their choice not to respond.
Of all the studies this investigator reviewed
98
Table 40 ·
RESPONSES TO QUESTION 17:
Question No. 17:
FREQUENCIES AND PERCENTAGES
What is your sex?
Response
Female
Male
absolute
frequency
adjusted
frequency
(per cent)
2
1.0
198
99.0
100%
200
missing cases:
8
99
which sent questionnaires to physicians, only Pauly
and Goldstein's study of 1970, reported in the article
"Physicians' Attitudes toward Premarital and Extramarital
Intercourse" mentioned any differences found between
female and male physician respondents.
They state:
"Fer.nale physicians are somewhat less accepting of
premarital intercourse for men or women, but they
demonstrate slightly less of a double standard in
this regard than their male colleagues."
(64:45)
There is no way of knowing if the female respondentn in this present survey are more or less accepting
of homosexual males than male respondents.
CHAPTER 8
CONCLUSIONS AND RECOMMENDATIONS
Conclusions
For a physician to successfully diagnose and
treat all cases of gonorrhea and syphilis in male
homosexual patients who walk through his office door,
the following events must occur:
i
1). He must obtain a sexual history;
patient
m~st
the
trust the physician enough to tell him
that he, the patient_, has engaged in rectal or oral
sex w:i. th another male.
2).
He must examine all three sites (urethra,
anal-rectal- area and pharynx) for signs of infection.
3).
He must culture all three sites;
he should
know that all of these sites, including the urethra
(6:779)
(16) can be asymptomatic yet still be infected.
4).
He must treat the patient with adequate
dosages of antibiotic if any signs of infection, or
any history of a gonorrhea or syphilis contact have
occurred.
He therefore must know that the dosage
adequate to cure urethral gonorrhea may not be adequate
to cure any rectal or pharyngeal gonorrhea that may be
100
101
present.
5).
He must do follow-up cultures, since ·failure
of cure even with antibiotic treatment occurs frequently.
(59)
This again infers that the patient must feel
comfortable enough with the physician (plus be adequately
motivated) t.o be willing to make a repeat visit.
The data from this study suggest that many of
the re8pondent physicians probably failed to diagnose
a large number of cases of gonorrhea, and perhaps
syphilis, in their gay male patients in 2977.
This
conclusion was made on the basis of the following
i
information;
whereas sixty per cent of those physicians
had seen male homosexual patients with DOSsible gonorrhea
or syphilis, only thirty-seven per·cent of the patients
told
~he
physician about their homosexuality.
Only
twenty-two per cent of the physicians always asked
their patients if they had had a homosexual contact.
Less than half of the physicians always examined
and/or cultured the pharyngeal and rectal areas on those
patie:..1ts whom they believed to be homosexual or bisexual.
Eighty-two per cent of the physicians believed that the
dosage of antibiotic they used to cure urethral gonorrhea
would be adequate to treat any rectal or pharyngeal
gononrhea also present.
It is to be noted that these
results are probably opti~istic, because it is very
possible that ·the physicians claimed a better grade of
102
clinical practice in their responses than was actually
the case.
Those physicians who knew that gonorrhea could be
asymptomatic were not necessarily the same physic:L';.c:..s
"who consistently examined the rectal and pharyngea.l.
sites in their gay male patients.
Those physicians
who had seen more gay male patients had a correspondingly
higher clinical practice score.
However, there was no
relationship between the attitude of physicians toward
gay male patients, their knowledge of the manifestations
and treatment of gonorrhea and syphilis in gay males,
~nd the physicians• clinicaf practice scores.
Knowledge
il
and attitude scores were both influenced by the physicians•
age.
One can conclude, therefore, that although
the respondent physicians• experience with gay male
patients influenced his clinical practice in adequately
diagnosing and treating gonorrhea and syphilis in that
population, his attitude toward gay males and the amount
of knowledge about the subject did not appear to
influence the adequacy of his clinical practice.
Therefore there must be other factors which influence
the physician to take thorough sexual histories and to
do regular three-site examinations on male patients he
knows or suspects to be homosexual.
It is quite possible
that some physicians are by habit simply more thorough
r:
103
and some also less inhibited than others by the need
to ask sexually reJ.ated questions or to examine.the
rectum and throats of gay male patients.
It must be emphasized that further studies of
physicians attitudes, knowledge and clinical practice
regarding V.D. in male homosexual patients are needed
to confirm the findings of this study.
Recommendations
The trend in health education at the present
time is to lay the burden
o~
obtaining knowledge about
I
and asking for treatment for any health problems on the
person who is at risk or affected.
Gay.health specialists
have been especially emphatic concerning the necessity
for gay people to take responsibility for their own
health needs.·
(This is because many gay people have
tended to avoid seeing physicians out of fear that, if
their sexual orientation
~ere
revealed to the physician,
the physician might respond to them in a negative manner.)
Gay health specialists encourage gay men to have regular,
frequent checkups for the sexually-transmitted diseases.
They also assert that the gay male patient must insist,
tnat the physician examine and culture the relevant·sites.
From the foregoing information I would make the
following recommendations:
1).
A well-publicized series of dialogues between
104
the medical community and the gay community should be
set up.
These two groups have traditionally been, in
general, very distrustful of each other.
If this survey
is in any way an accurate representation of physicians•
attitudes toward gay male patients, then most physicians
are not nearly as anti-homosexual (at least toward gay
males) as many gay people believe •. An ongoing dialogue,
about which members of both
com~unities
were kept well
informed, could have the following very important
effects:
a).
Gay males might be more willing to go
to physicians sooner or more frequently
for checkups if the medical profession
openly indicated a position of acceptance
of homosexuality, and the gay people
were given reason to believe this position.
b)o
More males might be willing to reveal to
physicians that they have had a homosexual
contact.
c).
More physicians might be willing to ask
questions about sexual contacts and less
embarassed (if that is the
p~oblem)
to do
three-site examinations on their patients.
d).
Improved acceptance by physicians of
homosexuality might indirectly result in
increased funds available for research
105
into vaccines and/or health education
~or
the gay male community.
This is
a possibility because the medical
profession as a whole has a tremendous
influence on allocation of funds for
medical and health causes.
2).
Increased research should be conducted to
discover what heal·th education approaches, if any, will
most influence gay males to effectively take responsibility
for controlling the spread of the venereal diseases in
their own population.
a).
Three rossible approaches would be:
traditional approaches such as pamphlets,
posters, television commercials, and
educati~nal
material available in
physicians• offices and clinics;
b).
an intensive, open and widespread campaign
conducted by and for the gay male community, focusing on all aspects of gay
venereal diseases, especially the needs
for keeping track of contacts, for
reg~lar
frequent checkups, and for three-site examination by physicians;
c).
increased health education for young
school children, with an emphasis on all
types of venereal diseases, on the yarious
types of sexual u.ctivities. and on the
106
relevance of each of the venereal diseases.
This would insure that,the next generation
of gay and bis0.xual men would have had
at least some exposure to health education
on the subject of the venereal diseases.
3).
Intensive research should be continued to
develop vaccines for the various sexually-transmitted
diseases, to be given to persons of high risk.
It may
be that this would be the only truly effective means ofcontrolling the diseases.
4).
At the same time tbat physicians are provided
with forms for reporting various diseases to their local
health departments, they should be given "three--site
culture sets,
1
11
each of which would contain culture media,
an anoscope, and information emphasizing _the necessity
of three-site testing on all males who might-have had
a homosexual contact.
5}.
Medical students should be provided with
increased exposure to gay life styles through meetings
with representative gay groups, informative films, etc.;
they should in addition be given very specific information
as to what will be expected of them as practicing physicians in dealing with men who may have contracted
venereal diseases while having sex with other males.
Physicians already practicing medicine should be provided
the same information in their continuing education classes.
. . .~
107
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114
APPENDIX A
INTRODUCTORY LETTER AND QUESTIONNAIRE
SENT TO THE SURVEY PHYSICIANS
115
Los Angeles· Venereal Disease Inf ornzatinn Council
Post Office Box 30607, Los Angeles, California
90030
Telephone: (213) 974-7764
January 13, 1978
Dear Doctor:·
The purpose of this letter is to ask your help with a study
relative to the diagnosis and treatment of syphilia and gonorrhea
of men in this community whose behavior is exclusively or
occasionally homosexual. The study is being conducted by the
Los Angeles Venereal Disease Information Council in conjunction
with Mrs. Christine Maqueira, a graduate student at the California State University, Northridge.
!
As you know, the incidence of gonorrhea and syphilis has
continued at epidemic proportions in the United States. These
infedions annually afflict thousands of people from all age groups.
The objective of this study, however, is to assess the prevalence
. of syphilis and gonorrhea among only those exclusively homosexual
and occasionally homosexual men seen by private physicians.
Moreover, it is hoped that this study will assist the private physician in the evaluation and management of these highly important
infectious d-~seases.
We do hope that you will take a moment to fill out and return
the attached questionnaire. Only with your cooperation can this
study be m~aningful and helpful. Thank you for your interest.
Sincerely,
Ralph R. S chs, M. D.
Vice President
Program Development_
RRS:CM:ir
Att.
116
SURVEY
Please complete every question. Please do not sign your name. You
may be assured of complete confidentiality:- Included is a line under
each question for your corr.:.ments regarding the relevance, wordi~ or
clarity of the question. Your comments will be used to make the
questionnaire more effective. Thank you.
l.
Approximately how many cases of suspected gonorrhea and
syphilis in all males did you see last year?
(
(
(
(
(
)
)
)
)
)
none
1 to 10
10 to 30
30 to 50
more than 50
Comr~1ents:
-------------~-------------------------------------
2.
Of those men who had gonorrhea or syphilis or their symptoms
approxi:"llately how many did you believe to be homosexual or
bisexual?
( ) none
( ) 1 to 5
( } 5 to 10
( } 10 to 30
( ) more than 30
Comments::
3.
What indications were there that these men might be homosexual
or bisexual?
4.
How often do you aak your male patients who request treatment for
possible syphilis or gonorrhea if they have had a homosexual contact?
( ) always
Comments:
( ) sometimes
( ) rarely
( ) never
---------·-------------
Page 2
5.
For those men whom you believed to be homosexual or bisexual, what
sites did you examine and,/ or culture for gonorrhea or _syphilis?
penile:
pharyngeal:
rectal:
do you ask him about sexual relations outside of his marriage?
( ) no
( ) yes
b.
c.
{ ) no
( ) sometimes
do you inspect and/ or culture his throat and rectum for signs of
...nfection?
( ) yes
Comments:
( ) no
( ) sometimes
-------~------
If you treat a male for penile gonorrhea do you believe that the dosage
of antibiotic you use is sufficient to cure any rectal or pharyngeal
gonorrhea that may also be present?
( ) no
{ ) yes
Comments:
( ) sometimes
----------------- -----------
In your professional opinion are pharyngeal and rectal gonorrhea
freque:atly asymptomatic?
pharyngeal gonorrhea::
rectal gonorrhea:
Comments::
9.
( ) sometimes
does your inquiry include questions about homosexual contacts?
( ) yes
8.
( ) never
( ) never
( ) never
If a patient whom you know to be a married man asks you for treatment
of gonorrhea,
a.
7.
( ) sometimes
( ) eometimes
( ) sometimes
------- .. --- ... --
Comments:
6.
( ) always
( ) always
( ) always
( ) yef:j
( ) yes
( ) no
( ) no
( ) undecided
( ) undecided
--------------------~---------
Would you rather not have openly homosexual men as regular patients?
( ) I would rather not
Comments:
------- -· .......... -
( ) I don't mind
... .
( ) undecided
117
Page 3
118
10.
Will you accept the referral of a hon'losextial for treatment?
( ) yes
11.
( ) no
Do you feel that homosexuality in men is:
a.
b.
c.
a social threat:
an illness:
a valid alternative to
heterosexuality:
immoral:·
an inborn trait of some
individuals:
d.
e.
( ) yes
( ) yes
(. ) no
( ) no
( ) undecided
( ) undecided
( ) yes
( ) yes
( ) no
( ) no
( ) undecided
( ) undecided
( ) yes
( ) no
( ) undecided
----- -··. ·- ........ --- ... ---------------
Comments:
12.
( ) undecided
What are your own feelings when a male homosexual patient asks you for
treatment? (mark as many as are applicable)
(
(
(
(
)
)
)
)
curiosity
dis comfort
dislike
neutral -- no special feelings
( ) acceptance
( ) pity
( ) other
-----------------
----------------------------
Comments::
13.
Do you believe that it is important for a physician to have some understanding of the male homosexual life style and sexual activities in orC:e·r
to adequately diagnose and treat him for syphilis and gonorrhea'?
( ) no
( ) yes
Comments:
14.
----- ·- -- ·--- -- ·-
( ) sometimes
--~ ~-----------
When you attended medical school how much information regardir..g
homosexual life styles and sexual activities was imparted to you?
( ) none
( ) little
( ) a lot
( ) some
To assist us in completing a descriptive analysis of this survey,
complete the following:
15.
What is the zip_ co~ of the area where you pr.actice?
16.
What is your age?
17. What is your sex?
_,_..._ ,1""1..,0 , _____ , ___...
.L!
( ) 20 to 29 years
( ) 30 to 39 years
( ) 40 to 49 years
(
) male
ple~se
( ) 50 to 59 years
( ) 60 to 69 years
( ) _70 or more
( ) female
Page 4
Many thanks. Just fold and return in the enclosed envelope.
postage is necessary. If you would like a copy of the results of the
survey please send a note to:Los Angeles Venereal Disease Information Counc1l
P. 0. Box 30607
Los Angeles, California 90030
No
119
120
APPENDIX B
LIST OF SIGNIFICANT CHI SQUARE RESULTS
AND CORRESPONDING PEARSON CORRELATION COEFFICIENTS
LIST OF SIGNIFICANT CHI SQUARE RESULTS AND CORRESPONDING
PEARSON CORRELATION COEFFICIENTS (P.C.C.}
TABLE
CHI SQUARE df
p
P.C.C.
12: Crosstabulation of Q.2 (how many
Homosex. or Bisex. by Practice
15.47
8
L .05
0.26
16:
17:
23:
24:
30:
31:
33:
Crosstabulation of Q. 3a (They
Told You) by Q. 4 (Ask if
Homosex. Contact)
.Q
L . oo5
L . oo5
0.67
L
.oo1
L . oo 1
0.67
L
.oo1
6
L . oo 1
0.39
L . oo1
123.27
4
L . 001
0.71
L
Crosstabulation of Q. 9 (Rather
Not Have Homosex. Pts.) by
Q. 11a. (Social Threat)
36.13
4
L . oo 1
0.38
L . 001
Crosstabulation of Q. ( (Rather
Not have Homosex Pts.) By
Q. 11c (Valid Alternative)
28.66
4
L
.001
0~35
L
·cross tabulation of Q. 13
(Under&tanding Life Style
Important) by Practice
14.03
4
L . oo5
0.35
L . 001
23.89
9
Crosstabulation of Q. 4 (Ask if
Homosex. Contact) by Q. 6b
(Question Homosex Contacts)
103.97
6
Crosstabulation of Q. 4 (Ask if
Homosex. Contact) by Q. 6c
(Culture Throat or Rectum)
35.31
Crosstabulation of Q. 5 (Exam
or Culture Pharyngeal) by Q.5
(Exam or Culture Rer.tal)
.
.oo1
.001
.......
t-.)
.....
LIST OF SIGNIFICANT CHI SQUARE RESULTS AND CORRESPONDING
PEARSON CORRELATION CO~FFICIENTS (P.C.C.) {continued)
TABLE
C_HI_ SQJJARE 9-f_ ______p
P • C. C.
37: Crosstabulation of Q. 16 (Age)
(3
by Attitude
28.21
-.30
L .001
38:
erosstabulation of Q. 16 (Age)
by Knowledge
18.45
8
L .o5
p
L .001
P.C.C. not signif.
.....
I\)
I\)
'~