The

NEW ENGLA ND JOURNAL

of

MEDICINE

Perspective
Health Hazards of Dont Ask, Dont Tell
Kenneth A. Katz, M.D., M.S.C.E.

n the federal judicial system and the U.S. Congress, the fight over the militarys dont ask, dont tell policy regarding homosexuality goes on. In September, Judge Virginia Phillips banned envice member who, several months ago, came to one of the municipal sexually transmitted disease (STD) clinics in San Diego County, California, where I serve as medical director. I took care of Petty Officer J. in the way Ive been trained since medical school: ascertain the problem, find out whats causing it, and fix it. So I asked, and Petty Officer J. told. He had had rectal pain and discharge for 2 days. His sex partners are men. He had recently had receptive anal intercourse. Hes negative for the human immunodeficiency virus (HIV). After taking Petty Officer J.s history, I performed a physical examination and obtained a sample of the rectal discharge. A Grams stain confirmed a diagnosis of

forcement of the policy, ruling that it violates gay, lesbian, and bisexual service members equalprotection and First Amendment rights. On November 1, 2010, however, a federal appeals court ruled that the policy could be enforced while the case, Log Cabin Republicans v. United States of America, works its way through the courts. Meanwhile, the prospects for repeal of dont ask, dont tell in this years defense-authorization bills in Congress remain limited. As a result, the military careers of many gay, lesbian, and bisexual service members are back in jeopardy. So, too, is the health of these service members, the military, and the country at large. Take the case of Petty Officer First Class J., an active-duty ser-

rectal gonorrhea. Following guidelines from the Centers for Disease Control and Prevention (CDC), I ordered treatment for gonorrhea: an intramuscular injection of 125 mg of ceftriaxone along with an oral dose of 1 g of azithromycin for empirical treatment of chlamydia. I also tested Petty Officer J. for gonorrhea of the throat and urethra, chlamydia of the rectum and urethra, syphilis, and HIV all tests that the CDC recommends at least yearly for men who have sex with men but not for men who have sex only with women. Petty Officer J. and I discussed how he could protect himself and his partners from getting and spreading STDs, including HIV. Again following CDC guidelines, I recommended that he return for gonorrhea screening in 3 months. Like all active-duty service members, Petty Officer J. has health care thats completely covered by the military. There is
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no shortage of military treatment facilities in San Diego County, where approximately 175,000 active-duty service members and their dependents live. So why had Petty Officer J. come to the municipal clinic? He would not be comfortable, he told me, discussing his sexual practices or his sexual partners with military clinicians. Doing so, he said, would jeopardize his military career under dont ask, dont tell. Not that it would come up, he said, telling me that in the nearly 10 years hes been on active duty, hes never been asked. And hes never told. Petty Officer J.s story is not unusual. Ive heard the same thing from scores of other activeduty service members Ive cared for clinically or interacted with socially. During a 2-month period in 2002, active-duty U.S. Navy sailors accounted for 9% of the clients of a gay mens health clinic in San Diego that was run by a community-based organization.1 And that clinics experience and my own reflect the needs of only those service members who take advantage of nonmilitary health care facilities; according to recent estimates, gays, lesbians, and bisexuals in the military number 66,000, or 2.2% of all military personnel.2 How many of them have no access to nonmilitary medical care? How many simply dont seek it? The military did revise its dont ask, dont tell policies earlier this year, prohibiting confidential disclosures of same-sex sexual behavior to medical professionals from being used in discharge procedures.3 But service members Ive talked to are unaware that the policy has changed. And even after I tell them about it, they say they still would not
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risk disclosing same-sex sexual behavior while dont ask, dont tell is in place. They probably wont be asked to. Colleagues of mine who are military clinicians have told me they typically dont ask about the sex of their patients sex partners, even if that information might be relevant clinically, because of dont ask, dont tell. Many of them have told me that they are not aware of changes to the policy that would allow them to inquire, confidentially, about their patients sexual behaviors. I myself encountered dont ask, dont tell roadblocks while working as a part-time attending dermatologist at Walter Reed Army Medical Center in Washington, DC, in 2007. When I asked a resident about the sexual history of a patient with genital warts, the resident said he hadnt taken one. When I asked him to, he declined. Only after the colonel overseeing the clinic assured the resident that he wouldnt be required to report a history of samesex sexual behavior, if disclosed, did the resident take a sexual history. Recognizing that dont ask, dont tell compromises the medical care of gay, lesbian, and bisexual service members by stymieing normal lines of questioning in clinical encounters, the American Medical Association rightly came out against the policy in 2009.4 On those same grounds, in November the Executive Committee of the California STD Controllers Association, on which I serve as secretarytreasurer, took a position in favor of repealing dont ask, dont tell. The ethical dilemmas that physicians face when attempting to provide appropriate clinical care in the context of dont ask, dont tell have also

been detailed in the medical literature.5 Moreover, the policy leads to wild-goose chases that squander public health resources. After being diagnosed with an STD at a military treatment facility, one active-duty gay service member told me, he was compelled to provide the names of and contact information for his sex partners, who were to be contacted by the treatment facility and informed that they had been exposed to an STD. Rather than identify the man with whom he had actually had sex, the service member provided the name of a female friend. He then called his friend to make sure she was prepped for a call from the military about an STD exposure. Sure enough, she was contacted by the facility. Meanwhile, the service member, on his own, told his male partner to go to the municipal STD clinic. The consequences of dont ask, dont tell are clear. Infections go undiagnosed. Service members and their partners go untreated. Appropriate STD- and HIV-prevention messages, tailored to the types of sex gay, lesbian, and bisexual service members are having, go undisseminated. In addition to gay troops themselves, the military as a whole also loses. STDs cause illness that can compromise troop readiness and increase the likelihood of HIV acquisition. Once infected with HIV, service members cannot, except in rare circumstances, be deployed on combat missions. Meanwhile, their health care costs, borne by the military, are substantial. Civilians also pay a price. A visit to any of the bars or Web sites popular among gay, lesbian, or bisexual service members in

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areas near military installations will clearly reveal the extent to which service members and civilians mingle socially and sexually. STD and HIV prevention must occur in all our communities, including the military, for it to have a chance of succeeding in any of them. We can do better for our service members, our military, and our country by allowing gay, lesbian, and bisexual service members to serve openly. To fail to do so, I believe, violates their constitutional rights. But it also, in very real ways, threatens their health and that of the community at large. In the meantime, Petty Officer J. told me he wouldnt be re-

turning to the clinic in 3 months for gonorrhea screening, as I had recommended. While the fight over dont ask, dont tell continued in the courtroom, Petty Officer J. was preparing to be deployed on a combat mission in Afghanistan.
Although this story is true, the initial representing the patients last name and his rank and branch of military service have been changed to protect his privacy. The views expressed in this article are those of the author and do not necessarily represent those of the institutions with which he is affiliated. Disclosure forms provided by the author are available with the full text of this article at NEJM.org. From the Graduate School of Public Health at San Diego State University and the Division of Dermatology at the University of California at San Diego.

This article (10.1056/NEJMp1012496) was published on December 1, 2010, at NEJM .org. 1. Smith DM. Active duty military personnel presenting for care at a Gay Mens Health Clinic. J Homosex 2008;54:277-9. 2. Gates GJ. Lesbian, gay, and bisexual men and women in the US military: updated estimates. Los Angeles: Williams Institute, January 2010. (http://www.law.ucla.edu/ williams institute/pdf/GLBmilitaryUpdate .pdf.) 3. Office of the Secretary of Defense. Summary of changes: revisions to the dont ask, dont tell regulations. (http://www.defense .gov/news/Summary%20of%20Changes% 20DADT.pdf.) 4. OReilly KB. AMA meeting: Dont ask, dont tell said to hurt patient care: repeal urged. American Medical News. November 23, 2009. (http://www.ama-assn.org/amednews/ 2009/11/23/prsc1123.htm.) 5. Nagel F. Repealing Dont Ask, Dont Tell a step forward in patient-physician trust. Virtual Mentor 2010;12:663-7.
Copyright 2010 Massachusetts Medical Society.

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