As a nurse practitioner, Dana understands the importance of getting a regular pelvic exam and Pap-smear but puts it off nonetheless. It’s not the procedure itself—simple and essentially painless—but what inevitably precedes it that’s so daunting. Spending time in the waiting room among other patients, all of them women, is something Dana dreads. That’s because Dana (not his real name) is a transgender man—he was born in a female body but identifies as male—and now that he’s in the process of transitioning medically from female to male, he says, “I definitely look like a man.” In fact, many transgender men—some of whom, he notes, are in denial about their female organs—“don’t get exams until later in life, and sometimes it’s too late.” Transgender women, who continue to require prostate exams, experience similar problems.
It’s not just transgender patients who face discomfort—and sometimes discrimination—when seeking health care. Gay men, lesbians and bisexuals often hesitate to see a doctor because they fear they won’t be understood by mainstream practitioners. When they do see a doctor, they’re often reluctant to open up about their personal lives, and that can have repercussions for both their mental and physical health.
“So much of what we do as primary-care doctors has to do with prevention and lifestyle,” says Dr. Howard Grossman, a primary-care physician. “If you don’t understand the parameters of somebody’s life, how can you do good preventive work with them?”
Grossman, himself a gay man, has had a successful practice in Manhattan for more than two decades. He crossed the river in June 2013 to open a second practice in Millburn, AlphaBetterCare, affiliated with the Overlook Medical Center in Summit. Both of his practices specialize in LGBT (lesbian, gay, bisexual and transgender) patients and HIV medicine.
Grossman’s practice is possibly the first of its kind in New Jersey with an LGBT focus. Thomas S. Ziering, a primary-care physician, founded a similar practice last year in Bernardsville. Ziering, who is also gay, is medical director of Summit Medical Group’s LGBTI service, with the I standing for “intersex,” describing a person whose sexual anatomy doesn’t fit the typical definitions of either male or female. Both doctors also treat straight patients.
Two practices, the doctors agree, aren’t nearly enough. Close to 4 percent of the state’s population—some 250,000 people—identify themselves as gay, and because not all of New Jersey’s LGBT residents are out of the closet, the real number could be substantially higher. Grossman expects that population to grow, given the migration of gay men and women, and particularly same-sex couples, from cities to the suburbs. “Around the country, as acceptance grows, LGBT folks are moving out of urban cores,” he says. “The problem is that health care hasn’t followed.”
When Grossman, a West Orange native, decided to open a practice in New Jersey, he thought bigotry would be his major challenge. In fact, he says, “the biggest problem is lack of awareness—we’re just not on anybody’s agenda”—except, perhaps, that of the patients themselves. This lack of mainstream awareness helps explain why both Grossman and Ziering treat patients from all over the state, some of whom drive as much as two hours for a visit.
Many of their patients tell them about negative experiences with other health practitioners. Luanne Peterpaul, an attorney in central Jersey and a patient of Ziering’s, stopped seeing a medical provider because she felt his jokes about her gender and sexuality were inappropriate. Other patients report that they’ve been chastised about their sexual orientation. Lorenzo, a 27-year-old occupational-therapy student who became a patient of Ziering’s in July, went to his family’s primary-care doctor a few years ago with a case of the flu. In the process of the exam, the doctor took an updated personal history, during which Lorenzo (not his real name) told her that he was gay. “At that point, she said to me, ‘You really should stop that, because there’s a chance that this could be HIV,’” he recalls. He was so unnerved by the experience that he put off seeing another doctor for two years.
According to a 2010 survey by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, 28 percent of the LGBT community have postponed medical care when they were sick or injured, citing concerns about discrimination. That’s of particular concern when you consider that the community is not only at higher risk of HIV, but, according to the Department of Health and Human Services, also more likely than the general population to drink alcohol, abuse drugs, smoke, become overweight, develop depression or commit suicide.
Grossman and Ziering not only accept their patients’ sexuality unconditionally, they consider it an important aspect of total wellness. They understand, too, that for at least some of their patients, sex—inextricably connected as it is with sexually transmitted diseases—is a critical health consideration. Grossman has a long history of working in HIV medicine, and Ziering did clinical research into HIV when he opened his first practice, in Bernardsville, in 1992.
Both doctors have their share of patients with HIV. For the past three years, Grossman has treated Tim Horn, a 20-year survivor of HIV who lives in Asbury Park and works in Manhattan at the AIDS research and policy think tank Treatment Action Group. “By far, the care from Dr. Grossman is the most comprehensive I have ever received,” says Horn. “In my experience,” Horn adds, “doctors who don’t specialize in LGBT health concerns talk about sex against the backdrop of disease. Dr. Grossman talks about it against a backdrop of health; he wants his patients to have the healthiest sex lives that they possibly can.”
What Grossman and Ziering don’t do is assume that, because patients are gay, they automatically have HIV—a prejudice that’s still common in the mainstream medical community. Grossman talks about a patient of his who went to an emergency room with chest pain: “He’s been in a monogamous relationship for 20 years, they have kids, and the first thing they wanted to do in the ER wasn’t a cardiogram but an HIV test.” Ziering is acutely aware of the emotional pain caused by that kind of attitude. In 1985, when he was still in medical school, he found himself in the hospital suffering from a headache, stiff neck, sensitivity to light and a high fever. He told the examining doctor about his sexual orientation. “I was automatically labeled as having AIDS,” he says. Ziering was put in isolation. He was asked if the hospital could test him for HIV; when he refused, he was tested anyway. It took two weeks to get the test results, during which time he was told that in a matter of months he’d likely die from a lymphoma of the brain. When the results finally did come back, it turned out he had sarcoidosis, a benign autoimmune disease.
That’s the kind of experience that has shaped the approach both men take to primary-care medicine. Ziering gives his e-mail address to patients so they can reach him anytime. “It gives them a level of comfort that I never had as a kid,” he says.
Grossman describes his own approach as nonjudgmental. “As a gay man,” he says, “being aware of the prejudice people face and the kind of hiding they’re forced to do, I’m very sensitive to the things that people are feeling judged about.” Such sensitivity is particularly important to transgender men and women, who are the most likely of the LGBT population to face prejudice from the medical community and the community at large. “They come in here so anxious and tightly held,” says Grossman, “and as we’re talking, and they see that I know what we’re talking about and that this is a completely accepting place, I just watch them relax and start to breathe.”
He remembers a time, in the early days of the AIDS crisis, when most doctors would get angry at patients who refused medication. Then one day he had an epiphany: “I thought, You know what? I’m here to take care of sick people; if they don’t want to take this, I’m not the one who’s going to get sick and die.” It was at that point that he decided he would no longer get angry at patients for refusing to do what he thought was the right thing.
His nonjudgmental attitude, he says, extends beyond sex and gender issues. When it comes to obesity, for example, Grossman, who lost 45 pounds over the past several years, wants his patients to know that he won’t be angry with them if they don’t lose weight—though he will be concerned. Instead of browbeating or scaring them into a weight-loss regimen, he shares his “fat picture,” he says. “and they’re like, ‘Oh, maybe I should listen to you.’”
Neither physician has had major problems attracting patients. Grossman reaches out through social media and community events like NJ Pride. As a former board member of the Gay and Lesbian Medical Association, Ziering gets referrals through the group’s website. Summit Medical Group, he says, has been enormously helpful in spreading the word about his practice. For both doctors, word of mouth has helped build a patient base, and LGBT patients often refer (straight as well as gay) family members.
The need for LGBT medical care is so acute in New Jersey, says Grossman, that he expects to focus increasingly on the Garden State practice. He’s hoping to soon be working with his nurse-practitioner patient, Dana, to offer gynecological services and prostate exams to transgender men and women, and he’s looking at ways to expand the practice. “There’s so much that needs to be done here in New Jersey,” he says. “I just think we could make a bigger impact and create real change for the people who need it.”
Leslie Garisto Pfaff is a longtime New Jersey Monthly contributor on health and education.