Black Man in a White Coat

by Damon Tweedy, M. D.

  Then disaster struck. During a routine gynecological checkup, her doctor discovered a slightly abnormal Pap smear. She was infected with human papilloma virus, a sexually transmitted infection (STI) identified as the main cause of cervical cancer. Based on this finding, he suggested testing for other STIs, including HIV. Monica scoffed at first. She’d had sex with two men in her life. With the first, a boyfriend in college, they’d always used condoms. She’d been careful with the second boyfriend too, but switched to birth control pills after dating for over a year. That turned out to be a life-altering decision: Monica’s test came back HIV-positive.

  Looking back, she remembered getting sick the year before and coming down with what she thought was a bad case of the flu. Working in a medical office, she figured that she’d caught the virus from one of the patients. But the symptoms she’d experienced were probably not from the flu; they were most likely from acute HIV infection.

  After absorbing the initial shock, Monica responded with the resolve that had gotten her out of the ghetto. She was fully compliant with her HIV medicines, taking more than a dozen pills each day spaced out over morning, afternoon, and evening. She did well for three years. She’d just applied for an administrative job at the local hospital and been invited for an interview when she got sick again. Over the course of a few weeks, a nagging cough wouldn’t go away and she lost almost ten pounds. Then one day she started coughing up blood. A chest X-ray at her local emergency room showed a large spot on her lung. She was transferred to Duke, where she was admitted to my team.

  I combed through Monica’s computerized chart to learn her history before meeting her. Most of the notes were from her hospital admission three years earlier and subsequent appointments in the infectious disease clinic she visited every three months. I caught myself looking for the entry that explained how she’d contracted HIV. Why was I doing that? After this long, it was doubtful that I could tell her anything she didn’t already know about how to avoid transmitting HIV to other people. Knowing the source of her infection certainly wasn’t going to change anything that we did for her medically. I had to wonder if I was looking for information that would allow me to pass judgment, the same way so many did back in the earliest days of HIV/AIDS, to determine whether an infected person was an innocent victim (someone with hemophilia, for example) or had made poor choices (an IV drug abuser or someone who engaged in high-risk, unprotected sex).

  On her initial outpatient clinic note, I found what I’d been searching for. There, an entry stated Monica had gotten HIV from a boyfriend. In my moral calculus, this put her somewhere between blameless and careless. As I approached her room, I felt that I had pried too deeply. There was nothing wrong with knowing how she got HIV, but why attach moral judgments to it? I wondered why this habit was so hard to avoid.

  I tapped on the door of her room and entered before she could reply. Anywhere else in life, I would have been appropriately shunned for my rudeness, but among doctors in hospitals and clinics, this was standard practice. The patients, dependent on our services, rarely offered any protest. Still, I felt embarrassed as I saw her reach to close her hospital gown, which was open in the back. I apologized for rushing in as I introduced myself. Her face relaxed.

  “Nice to meet you,” she said, her almond-shaped eyes staring up at me.

  Her skin had a few dark spots across her forehead, a remnant of teenage acne. She wore braces, like I had a few years before. This tiny detail connected us. We were nearly the same age. In another life, she could have been someone I’d grown up with or someone I worked alongside. Instead, she was a sick woman who might not live to see thirty.

  She’d tested negative for tuberculosis at the other hospital. But she kept coughing up blood, although a medicine she’d been given had slowed this down. Our plan was to schedule a lung biopsy to determine whether she might have cancer.

  “If I have cancer,” she began, “could that be from having HIV?”

  I nodded. Some cancers, such as Kaposi’s sarcoma and non-Hodgkin lymphoma, develop as the immune system progressively breaks down. They are among several “AIDS-defining illnesses,” whose presence indicates that a patient has gone from HIV infection to active AIDS. Since the advent of highly active antiretroviral therapy (HAART) in the mid-1990s, the incidence of these AIDS-defining cancers has decreased greatly. Lung cancer is also more common in patients with HIV/AIDS—for reasons that are not fully understood—but its rates have not declined much despite HAART.

  Monica started to cry softly. “I just can’t believe that I’m going through all of this.”

  She told me her story. Her second boyfriend, Larry, had been a drug company representative who’d come to her office marketing a new blood pressure medicine. He had impressed her with his intelligence, charisma, and ambition—he was applying to pharmacy school and eventually wanted to start a chain of pharmacies. Unlike the people she’d grown up around, Larry was a black man who was doing something with his life.

  “I thought I knew him,” she said, wiping at her tears.

  Standing there in her room, fresh off hunting through her chart for the source of her infection, I could easily have condemned her choices. But I wasn’t perfect. While I went through high school, college, and half of medical school without putting myself at any risk, during my third year of medical school I had unprotected sex with a woman that I didn’t know very well. I accepted without a thought her claim that she was HIV-negative and took birth control pills. That I came out of the situation unscathed didn’t change the fact that I’d been more reckless than Monica had. Clearly, HIV was not simply a matter of morality or assigning blame.

  Later that day, I met Monica’s mother, Geraldine. I had stopped to collect a blood sample only to find Geraldine, as Monica had gone down to the radiology suite for a CT scan. I tried to slip out, but Geraldine would have none of it. After a brief introduction, she wasted no time grilling me on Monica’s care.

  “So what’s this test for, exactly?” she asked.

  I explained to her that the CT scan had been ordered to get a better look at the spot found on the X-ray at the other hospital, and also to see if there were any other spots elsewhere.

  We talked about Monica’s care for several minutes before the conversation turned personal. “How long have you been married?” she asked, pointing to my wedding band.

  “Three months,” I said, smiling as I thought about my recent honeymoon in Jamaica.

  “That’s great,” she said. “You know, I wish Monica could have met someone like you.”

  I had heard this from black mothers before. Usually they were referring to the fact that I was college-educated, a professional-to-be, “someone who had his life together,” in contrast to the familiar narrative of black men “not doing right,” as my mom and grandma liked to say. But Geraldine was speaking on a different, more visceral level: “Monica wouldn’t have ended up like this if she’d found a real man.”

  I felt a skittish sensation envelop me. “What do you mean?”

  Geraldine looked away and stared out the window, frowning in disgust: “Her so-called boyfriend. The one that gave her this … disease. He was a fairy. A faggot.”

  I cringed. Words I had once used now sounded like instruments of ignorance and hate. Monica had not given any details about how Larry acquired HIV. Nor did I think it was my place to ask her.

  I told Geraldine that I was sorry about what had happened to Monica. There wasn’t much else to say. Two days later, the news got even worse: Monica was diagnosed with lung cancer.

  Monica was the first woman I took care of with HIV. In the ensuing years, I’ve seen many more. Women now account for nearly a quarter of all people infected with HIV. The CDC documented the first two cases of AIDS in women in 1983, two years after initial reports of the disease. Both women had acquired HIV through heterosexual sex with intravenous drug users. Foreshadowing the color of the epidemic to come, one of these two women was black and the other was Hispanic. B
y the late 1980s, blacks accounted for half of all HIV cases in women; most recent estimates place that number at more than 60 percent. In 2010, the rate of new HIV infections for black women was twenty times higher than the rate for white women, and black women accounted for nearly 65 percent of all deaths among women due to HIV/AIDS. Not surprisingly, black children remain far more likely than white children to be diagnosed with HIV.

  Many elements account for the higher rates of HIV/AIDS in the black community: poverty and low education, less access to health care, and higher rates of other sexually transmitted diseases. But I left the general medicine service struck by the impact of another factor, sexual dishonesty. Not only had George and Larry been unfaithful to their female partners, but, perhaps, they hadn’t been truthful to themselves either. As I grappled with their stories, I reflected on the role that homophobia, particularly within the black community, may have played in their actions.

  * * *

  One morning when I was six years old, I was waiting at my neighborhood bus stop when a boy my age who lived at the other end of the street came up to me. “Are you a fag?” he asked. At that age, I had no idea what that meant. Judging from the smile on his face, however, and the teasing stares of some of the older kids around us, I sensed it was something bad.

  “No,” I said, praying this was the right answer.

  “Good,” he said, “’Cause I don’t play with fags.”

  From then on, I was determined never to do anything that might make that label apply to me. During recess in elementary school, we sometimes played a game called “smear the queer,” where the person who held the football was “the queer.” I doubt the kids knew what queer meant, at least not in the adult sense. I certainly did not. But I made sure to never be “the queer.”

  By the time I became a teenager and began to understand the basics of sex, words like queer and fag had been so equated with weakness and inferiority that it seemed only natural for me to look down on gays and want to separate myself from them—especially from gay men. My parents, conservative in all matters sexual, did not approve of gay relationships, but they never had much to say on the subject, in contrast to the special condemnation gay people received at the hands of preachers I saw on television or read about in newspapers. Rather, they simply dumped homosexual behavior into the cauldron with all other sexual acts that took place outside the confines of traditional marriage and was thus to be avoided. Looking back, even if they had been openly supportive of same-sex relationships, I’m not sure that they could have counteracted the vicious antigay message I was hearing all around me.

  During basketball practices and games, whenever we played poorly, some coaches and older players would say that we were acting like fags or sissies, as motivation to make us work harder and perform better. We, in turn, used that same language to taunt our teammates and opponents. Back then I used those words more times than I can count. I never openly ridiculed anyone or harbored any violent impulses toward kids I thought might actually be gay. I simply avoided them.

  My homophobia persisted in college. One day after a game or practice, a black teammate, talking about a gay singer or actor he’d seen on television, proclaimed that if his son ever started to act effeminate, he would “beat it out of him.” With his quick temper, there was every reason to believe that he was serious. Two or three teammates chimed in, agreeing with him. A few others laughed or smiled. I shrugged in tacit acceptance, as if trying to beat homosexuality out of your own child made as much sense as attacking someone who’d harmed your family. Or maybe I shrugged because we’d all heard so many statements like this before that it hardly seemed remarkable. No one objected or seemed troubled by his ignorant rant.

  That same year, I was having lunch with a group of classmates, all black men, when we had a similar discussion. “There is no way I could have a gay son,” Allan said.

  “Maybe it’s not in your control,” his roommate said. “Maybe people are born like that.”

  “That’s crap,” Allan replied. “It ain’t natural. It’s all about how you raise your kids. Dudes turn out that way when they don’t have a strong male influence.”

  The notion that being raised by a woman would make a man desire another man doesn’t make sense, especially given how many black boys are raised by single moms, but we all accepted his flawed logic. He won the argument with a stupid answer.

  My attitude finally began to change during medical school where I worked with a few gay doctors and medical students, the first people I’d known well who were openly gay. I realized that in our shared experience in the medical field, our lives had a lot more similarities than differences. Further, my medical education revealed a certain commonality shared by all people. Even if one sexual, racial, or gender group got a given disease more frequently than another, all of us were vulnerable to sickness, injury, and, ultimately, death. From all I could tell, gay people, like everyone else, sometimes dealt with these problems well and sometimes did not. Across the span of a person’s life, where so many things, both good and bad, could occur, being gay (or not) was just one part of any narrative.

  The medical profession has historically suffered from similar homophobia. Until the early 1970s, homosexuality was regarded as an official psychiatric illness. Dr. Mark Schuster, chief of general pediatrics at Boston Children’s Hospital, has spoken at length about his experiences as a gay Harvard medical student during the 1980s, when some doctors openly discriminated against gay patients and medical students. Schuster once saw a surgeon refuse to operate on a patient whom he suspected of being a lesbian. Later, when Schuster came out to a professor who’d previously given high praise to his work, the professor revoked his offer to write Schuster a recommendation for pediatrics training. Shuster reflected that he often found himself in the burdensome position of choosing between being a doctor and being openly gay.

  Surgeon and writer Pauline Chen recounted a similar version of medical antigay bias in a 2012 New York Times article, in which a supervising physician during her training chastised a group of young doctors for prescribing a “homosexual dose” of medication, meaning one too weak to properly treat the patient’s problem. During my own surgery rotation in the late 1990s, the senior surgeon, frustrated with his junior colleague’s efforts, told him that he was “operating like a fag.” In each case, powerful people were using homosexuality as a proxy for weakness and incompetence.

  By the time I met George and Monica, I’d grown up enough during medical school to begin moving past this sort of bias, at least enough to recognize it when I saw it and to take care never to perpetuate it through my words or actions. As a black man, hating gay people simply didn’t add up. How could I get upset about being discriminated against because of my race while ignoring, or worse yet, being a part of, prejudice that others faced?

  But many blacks see it differently. In the era of HIV/AIDS, much has been said and written about homophobia within our community. Black people are often described as the most homophobic racial group in America. There is some data to support this contention. In 2008, black voters supported California’s Proposition 8 renouncing marriage rights for gay couples at higher levels than all other racial groups. A 2013 Pew Research Center poll showed that while half of whites supported same-sex marriage, just over a third of black respondents felt similarly.

  Based on the comments of public figures, as well as private discussions I’ve been part of over the years, it’s clear that many black people reject a link between the civil rights struggles of the 1950s and 1960s and the contemporary legal efforts on behalf of gay people. Barack Obama framed the issue during a 2008 presidential campaign speech, which took place at Ebenezer Baptist Church in Atlanta, Dr. Martin Luther King Jr.’s church. “If we are honest with ourselves,” Obama said, “we’ll acknowledge that our own community has not always been as true to King’s vision of a beloved community. We have scorned our gay brothers and sisters instead of embracing them.” It was fitting that Obama’s com
ments took place where they did, as black churches are widely seen as a main source in shaping the community’s antagonistic attitude toward gays. In some of the black churches I’ve attended, the antigay sentiment has ranged from tacit disapproval to outright denunciation. For every Reverend Calvin Butts in Harlem and Reverend Dennis Wiley in Washington, D.C., both supporters of gay rights and acceptance, there are many more clergy who take the opposite stance.

  In recent years, a handful of gay black celebrities have spoken on the issue. In a 2011 interview with the New York Times, CNN anchor Don Lemon asserted that being gay is “about the worst thing you can be in black culture. You’re taught you have to be a man; you have to be masculine. In the black community, they think you can pray the gay away.” Lee Daniels, director of the movies Precious and The Butler offered a similar perspective, saying: “Black men can’t come out. Why? Because you simply can’t do it. Your family says it. Your church says it. Your teachers say it. Your parents say it. Your friends say it. Your work says it.”

  To be sure, certain white churches, public figures, and political organizations can be equally virulent, if not worse, in their condemnation of gays. Hispanic and Asian cultures also possess their own share of homophobia. But when it comes to how these beliefs intersect with health, blacks are the group least able to afford such attitudes. In 2010, the Centers for Disease Control and Prevention reported that gay and bisexual black men, despite being a much smaller group than white gay and bisexual men, accounted for approximately the same number of new HIV infections; in 2011, this black group surpassed their white counterparts. Among the many causes of higher HIV/AIDS rates among black people, homophobia and the resulting sexual secrecy clearly play an important role. The time has come for the black community to confront some of its prejudices toward gay people.