The Health Hazards of “Don’t Ask, Don’t Tell:” A View from the Clinic


This article was amended at 12:48 p.m. Friday, December 3rd, 2010 to fix a typo in this sentence in the last paragraph, which now reads correctly as follows:

The sailor also told me he would not return to see me for retesting for gonorrhea in three months, as I recommended, following CDC guidelines. He was, he explained, about to be deployed on a combat mission in Afghanistan.

On December 1, The New England Journal of Medicine published an article I wrote entitled “Health Hazards of ‘Don’t Ask, Don’t Tell.’” The article describes how the military’s policy on homosexuality imperils the health of service members, the military, and the country, and it advocates for repeal of the policy on those grounds.

I have to say that, until last year, I never anticipated publishing an article about “don’t ask, don’t tell.” I have always supported repeal of the policy. But I’m a physician and public-health practitioner, not a policy wonk, lawyer, or expert on military affairs. And I’ve never served in the military myself.

What changed? Well, in 2009 I moved to San Diego, California, to take a job as medical director of the municipal STD clinics in San Diego and as director of public health efforts to prevent and control STDs in the community. San Diego has proved different from places I’ve lived in the past. It’s not just sunnier. It’s a whole lot more military. In fact, about 175,000 active-duty service members and their dependents live in San Diego. And considering that an estimated 2.2 percent of military personnel are lesbian, gay, or bisexual (LGB), it should not be a surprise that a fair number of them are LGB.

I know that first-hand, because I frequently care for active-duty service members, including LGB service members, in the municipal clinics. And, as I do for every patient I see, I take a sexual history. I ask my patients who they have sex with, what types of sex they’re having with their partners, whether they’re using protection. In doing so, I’m simply doing what I’ve been trained to so since my very first day of medical school: find out what the problem is, and fix it. And, when it comes to sexual health, those questions are critical to me, in determining which screening tests to order, which diagnoses to consider, and which STD and HIV prevention messages I should provide. For example, guidelines from the Centers for Disease Control and Prevention (CDC) regarding STD screening are different for men who have sex with men who than they are for men who have sex only with women.

What happens when I ask my patients those intimate questions? Well, for the most part, whether my patients are men or women, gay or straight, military or civilian, they tell. They know that I need that information to help them. And they want to be helped. They want to be – or stay – healthy, after all. That’s why they came to see me in the first place.

The problem with “don’t ask, don’t tell” is that it’s a giant roadblock in the middle of the typical “ask” and “tell” encounter that’s absolutely essential to the effective practice of medicine. It’s like trying to take care of a patient with chest pain without being able to ask him whether he smokes, or has a history of heart disease, or has ever had a heart attack in the past. It’s not good medicine.

But, unfortunately, that’s exactly what happens in many military healthcare settings, according to scores of military clinicians and service members with whom I’ve talked. Military clinicians don’t ask, and service members don’t tell. No matter that the Department of Defense last year exempted use of disclosures of same-sex sexual behavior from use under “don’t ask, don’t tell” procedures. Many military clinicians and service members I’ve talked to aren’t aware of that exemption. Even after I tell them about it, military clinicians and service members say they still won’t ask and won’t tell. As one military physician wrote me after reading my article: “Training in military medicine will also have to change with the times because I/we have never been previously trained in taking appropriate sexual histories.”

The upshot is that infections among service members go undiagnosed and untreated – unless they come see me, or another civilian provider proficient in sexual health. There are certainly many more service members who don’t know about, or don’t have access to, municipal clinics. In those cases, we all lose. If infections go undiagnosed and untreated, our public health efforts to break the chain of transmission of STDs and HIV are undermined. That goes for our efforts in both the military and the civilian populations, which in San Diego, and many other areas across the country, have a huge amount of social – and sexual — overlap.

STDs, of course, compromise military readiness, whether they’re among LGB service members or not. And they also predispose to HIV acquisition, which itself is unfortunate for a service member and costly, in terms of readiness and healthcare expenses, for the military.

The best way to make sure our service members stay healthy is to remove the “don’t’ ask, don’t tell” roadblock. Repealing “don’t ask, don’t tell” will have health benefits for service members, the military, and the country. Don’t we owe it to our men and women in uniform, who are called on to sacrifice so much for us every day, to make sure we’re doing our part to protect their health?

The Department of Defense this week released survey results indicating that 70 percent of service members say that repeal of “don’t ask, don’t tell” would have positive or mixed impact, or no impact at all, on their units. And there’s some hope that the U.S. Senate will vote on repeal of the policy before the lame duck session ends this month.

But in the meantime, active-duty service members continue to come to the municipal clinics. They include people like the sailor I describe in The New England Journal of Medicine, a gay man I diagnosed with an STD. He would never, he told me, go to a military clinic with a problem like that, so long as “don’t ask, don’t tell” was the law of the land. Doing so would pose too great a risk to his career.  The sailor also told me he would not return to see me for retesting for gonorrhea in three months, as I recommended, following CDC guidelines. He was, he explained, about to be deployed on a combat mission in Afghanistan.

______________________

Kenneth A. Katz, MD, MSc, MSCE is an Associate Member of the National Coalition of STD Directors (NCSD) and a physician and public-health practitioner in San Diego, California, who focuses on STDs. He is an Associate Adjunct Professor at the Graduate School of Public Health at San Diego State University and a Voluntary Assistant Clinical Professor in the Division of Dermatology at the University of California at San Diego.

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  • amykaron

    Dr. Katz,

    Thanks for this excellent blog post, and congratulations on your article in NEJ.

    I was taken aback to read the military physician’s comment that he and his colleagues ”have never been trained in taking appropriate sexual histories.” This implies to me that any service member, LGB or straight, who goes to a military clinic typically won’t be asked questions that could help diagnose an STD. Is that the case?  This strikes me as a grave error — not only because it’s unfair to our military personnel, but also because those who serve in war zones must be absolutely combat-ready. Any illness could compromise not only their own safety, but also that of their unit.

    Amy Karon

    Science and health writer

    Madison, WI

  • jagusmc

    While I find this article interesting, I have to say given my years in the Marines, every time I have gone to medical w/anything beyond the common cold, I was asked in-depth questions.  Depending on the circumstances, the questions were related to finding out & diagnosing my problem.  STD’s aren’t limited to gay service members & I have to say any military doctor who states that he/she “have never been trained in taking appropriate sexual histories” either slept thru medical school and/or is a poor physician.  I have only had 1 std during my entire life & it was my first yr in the military.   Chlamydia.  I was asked in-depth questions in regards to who, where and how exactly I might have gotten chlamydia. The questions were much more invasive than my own non-military doctor would have asked in the same situation & this was 1994.  The doctor asked outright if my sexual partners were female or male, the name of my sexual partner, her contact information and where I was when I engaged in sex with her (gotta love american airlines flight attendants).  Mind you, the military had just adopted the DADT policy.

    If a military doctor stated they did not ask, it’s not because they are trained improperly, it’s because they clearly are not comfortable with asking certain questions and that “doctor” is doing their fellow service members a huge disservice.

    Since STD’s are not gender specific or military specific, why is DADT even an issue in the civilian medical community.  Either way, a doctor should be asking a persons sexual history and unless the military patient distrusts & feels a civilian doctor will report his/her homosexual omissions to his command, DADT’s possible repeal shouldnt even be an issue to non military doctors.  

    Anal sex is not gay specific, & std’s are not gay specific.  A GREAT many heterosexual males engage in anal sex w/their wives and girlfriends… enough so that the CDC tries to avoid listing anal sex as a possible reason a percentage of heterosexuals have acquired hiv because of the misconception that anal sex is strictly a gay thing.  Clearly that isn’t the case since there are many self proclaimed gay men who do not engage in anal sex and actually abhor the idea.  But do doctors ask every heterosexual male they treat for a std if they engage in anal sex with their wives and girlfriends? No, but they proceed on the assumption all gay men do engage in anal sex.

    While I understand the reality is that there are a great many homosexual identified service members and there always have been since the military’s inception & I have no problem with that and I know & am proud to serve with several homosexual service members, I have to wonder if your desire for a repeal is because of a strictly professional reason or a more personal & political reason, despite the protest otherwise?  A repeal or a non repeal shouldn’t have any affect on the quality of medical care a person receives and those personal sex history questions apply to both hetero and homo alike… but when was the last time a doctor asked a heterosexual male if he engaged in anal sex or if he performed oral sex on his wife/girlfriend… slim to none odds.  

    Dont ask Dont tell isn’t the issue or problem.  Feeling comfortable enough to be honest w/a physician about sexual history is but if a doctor takes a one sided stance about std’s and homosexuals as the above article indicates & tries to tie it into a political policy that has nothing to do w/the civilian community, I have to wonder if 1. Is the author gay himself; and 2. Is the medical platform being used to state a personal political opinion.


  • arekushieru

    Jagusmc, you seem to be implying that heterosexual military personnel have it just as hard (or harder) than homosexual members by mere dint of the fact that their medical histories aren’t taken the same way they are in the case of the latter.  This sounds much like men’s rights activists complaining that they have it just as hard as women because they’re stereotyped by society just as much as women are, completely ignoring the fact that the stereotypes for men are standards that beget an upward movement while the stereotypes for women are standards that beget a downward movement.  Iow, heterosexual medical histories aren’t taken in the same way as homosexual military personnel are, because it is assumed that there is no way that heterosexual members would engage in such (assumed) dangerous and risky behaviour. 

    Which is why DADT must be repealed.  Stigmatization and discrimination abound in its presence, making it VERY unlikely that what even you described as the root problem will ever be addressed, under those circumstances.

    Btw, I have no idea what real relevance the civilian community has to any of this?