As Dr. Katherine O'Hanlan listened to her colleagues at a national meeting on breast cancer, she wasn't surprised that no one mentioned lesbians.
The meeting, held by Health and Human Services Secretary Donna Shalala, was focusing on minority women's low access to cancer screening.
"Everyone kept talking about minority women's access to mammography screening," recalled O'Hanlan, a gynecological cancer surgeon at Stanford. African Americans, Latinos--each had poor mammography rates. But no one was mentioning gay women.
Then O'Hanlan took the floor. Lesbians, she pointed out, were the least likely to go for mammograms but, for reasons that are unclear, have among the highest rates of breast cancer.
"Because Shalala had invited me to that meeting, we were able to ask that all future research on breast cancer (include) sexual orientation," O'Hanlan recalled. Several large upcoming studies, including the sweeping Women's Health Initiative, will stratify data by sexual orientation.
The story illustrates one of many recent inroads that can be claimed by the nation's predominant group of gay doctors--the American Assn. of Physicians for Human Rights--of which O'Hanlan is president.
As gay rights takes on greater importance under the Clinton Administration and with increasing social tolerance, this 13-year-old medical society is seizing the opportunity to make its mark, its leaders say.
"This organization has always had enormous potential. But I think we're tapping into it more than ever before," said Benjamin Schatz, who took over as executive director of the San Francisco-based group in 1992.
For example, Schatz said, when the American Medical Assn. recently convened a select group of members to discuss the future of medicine, AAPHR was asked to send a representative.
"That would never have happened even a few years ago," Schatz said. "We're finally getting somewhere."
The group's burgeoning presence is reflected in numbers; membership has almost tripled since 1993 to 1,200 members, and that number is expected to reach 2,000 by year's end.
But the expansion has had a price. Growing pains are obvious as the organization struggles to define its identity. It's thorniest problem is whether to change the cumbersome and euphemistic name to one that would clearly denote a homosexual orientation.
Members have until Friday to return ballots on the proposed name change, and Schatz, who is overseeing the vote, said he has no idea what the outcome will be.
The group's dilemma reflects the same struggle facing gay doctors all over the country: whether to divulge their sexual identities to patients and colleagues.
The anguish of this decision was apparent in the group's recent newsletter. Said O'Hanlan, who suggests a name such as Gay and Lesbian American Medical Assn.: "As agents of change, our most powerful tool is our visibility."
But, said another member, writing from a small rural town: "I cannot risk being associated with anything that would identify me as being gay . . . (it) would destroy my practice and throw me into bankruptcy."
Schatz sighed when asked about the turmoil accompanying the name change.
"We're turning 13. This is our bar mitzvah year," he said. "We are becoming an adult organization. And we are trying to find our identity and figure out what we'll be doing the rest of our lives. You can't change this much without conflicts. But that's good. It means people care about the organization."
Members give different reasons for why, after 13 years, both membership and outside acceptance have suddenly soared.
"I don't think it's a coincidence that our membership increased during the Clinton presidency," Schatz said, noting that membership in other gay doctors groups--such as medical students, lesbian doctors and medical specialty groups--has also risen. "I think the gay and lesbian community, as a whole, was exhausted (during the Reagan and Bush eras) by being seen as second-class citizens."
O'Hanlan said the rising number of openly gay doctors is similar to what is occurring in other professions.
"Gay and lesbian doctors have become fed up with homophobia. I think we have less patience for it now. More of us are saying, 'We ought not to hide.' "
But the debate over a possible name change shows that it is not that easy to put one's beliefs before practical considerations. Many doctors within the organization say they fear a name change would jeopardize their practices.
Belonging to an openly gay group, they say, would put them one step closer to being "outed" in communities that are not ready for them. About half of AAPHR members have practices that treat mostly heterosexuals.
"Most gay and lesbian physicians feel very isolated," Schatz said. "Seventy percent of our members are outside New York and California. Chances are they are in a center in which they are the only one."
AAPHR leaders acknowledge this fear. In a recent member survey, the majority said they had experienced professional problems related to their sexual orientation. Almost two-thirds of the doctors said they thought their practices would be jeopardized if their colleagues found out they were gay. And almost 75% believed that they would suffer if their patients found out.
Seventeen percent said they had been refused medical privileges, fired or denied educational opportunities, employment or promotions because of their sexual orientation.
One California psychiatrist, who asked not to be named, recalled applying for a psychiatric residency in Massachusetts and receiving an unexpected rejection letter.
"I later found out from others on the committee that I had been selected, but the committee chairman had rejected me because he wasn't comfortable having a gay resident," the doctor said.
For those who stay in the closet, membership with the AAPHR helps fight the feeling of isolation and loneliness, O'Hanlan said.
"Medical school was one of the most difficult times of my life," she said. "At the time, I was becoming aware I was a lesbian. Not only did I think I was the only doctor like this, I thought I was the only person like this."
Even though he has publicly acknowledged his homosexuality and works in a very supportive community, Dr. Mark Litwin, a urological surgeon who is also on the faculty of UCLA, said he draws support from AAPHR.
"AAPHR allowed me to feel comfortable knowing I am not the only gay physician in the world," Litwin said. "Many of our issues are the same. Such as, what is going to happen to me if I come out professionally? What I found, to my pleasant surprise, is nothing changed."
Coming out as a group, however, may be more difficult. Litwin, like others, worries that his gay colleagues in more isolated areas might feel uncomfortable if the group changes its name.
The AAPHR focus, however, goes well beyond its members' concerns. The group's mission is also to work to improve the health of gay men and lesbians. In the past year, the group has started a Lesbian Health Project and this month will host a medical conference on HIV prevention among gays.
"The debate over gay and lesbian rights has been very much an issue of civil rights," Schatz said. "But there are so many ways in which homophobia has an impact on health. Discrimination is not only unfair but harmful to health."
For example, surveys have shown a high level of discomfort with homosexuality among heterosexual doctors. In one study of 1,121 primary care doctors, 35% said they would feel nervous among a group of homosexuals. And a survey of 930 doctors in San Diego showed almost a quarter biased against gays.
Many gays, fearing rebuke, either refuse to seek medical care or hide their sexual orientation from their doctors, Schatz said.
"Most (homosexuals) go and hope the doctor is not going to hate them and will be somewhat knowledgeable," Schatz said. "Gays and lesbians deserve better than that. People shouldn't have to play medical Russian roulette."
AAPHR has worked with several medical specialty groups to urge them to welcome gay patients by adding non-discrimination statements to their bylaws and rewriting patient literature so it is sensitive to people of any sexual orientation.
Dr. Roy Schwarz, a vice president of the powerful AMA, credits Schatz with persuading the AMA to add a sexual-orientation non-discrimination clause to its bylaws last year. The AMA had refused similar requests in four previous years.
"He made a lot of converts when he spoke on the floor to our house of delegates," Schwarz said.
Besides the AMA, the 30,000-member American Medical Women's Assn. last November officially banned discrimination based on sexual orientation. But that is just a start.
"It's going to be a long process," Schatz said. "It's a monumental task, not a small problem. We're talking about a profession in which anti-gay sentiment is pervasive."
Doctors should lead the way in dispelling homophobia, O'Hanlan said.
"The problem is that health professionals, who are frequently seen as the pillars of society, are no more educated about gay and lesbian people than the general public," she said. "Physicians could, potentially, be leaders in disseminating accurate information about gay and lesbian people. But instead they follow."
For now, the AAPHR is leading this movement and has chosen to work quietly and professionally--within mainstream medicine--to lobby for change. Most of the organization's members--60% of whom are male--are interested in science, not politics, O'Hanlan noted.
"We're distinguished physicians," she said. "Most of us are authors in our respective fields. We deserve to be recognized by people like Donna Shalala."
But whether the group can gain power under the guise of a misleading name is its biggest question.
Whatever happens, Schatz said he does wish that the office would stop getting calls from people "concerned about political prisoners in Costa Rica."
"People don't know what we do," he lamented. "Our name impinges on people hearing about what we do. We shouldn't be an organization whose name is in the closet."