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Marriage equality, in sickness and in health

Dan Page/-

Not long ago I fractured my shoulder and needed surgery. After the operation, my husband of 30 years did all the things a loving spouse would be expected to do: He fluffed my pillows and put toothpaste on my toothbrush (try doing that with one arm!) and overlooked my crankiness.

My husband also helped me in ways so fundamental to our status as a married couple that I barely registered them. When I was loopy after the operation, he spoke with the surgeon on my behalf; he signed me out when I was discharged; health insurance through his employer covered my medical expenses.


Right now, thousands of couples in the United States can't take these things for granted as we did. Lesbian and gay couples who are as deeply committed as my husband and I are, who've shared private jokes and dumb arguments, budget-making and childrearing just as we have, can't count on being able to fully support one another when one of them is ill or injured. Even in the handful of states where same-sex couples can legally marry, rights including spousal health-care benefits are not guaranteed.

If you Google "marriage equality" and "health care," they are likely to appear on a list of important but unrelated issues. (The first link that popped up for me, from a local newspaper in Oregon, mentioned: "Marriage equality, better health care, salmon habitats . . . ") But, of course, they are related. In our current political discourse, issues are labeled "social" or "economic" or "civil rights," and so forth, but both marriage equality and health care involve all of these — and each other.

Medical professionals are in a unique position to see controversial issues in a multifaceted way because we get to know a variety of people – our patients – so intimately. The view is more nuanced behind the closed doors of the exam room than it is on Fox News or MSNBC, or on the campaign trail. For example, no matter what a doctor's personal stance on abortion is, he or she must deal with the complex emotional, physical, and psychological needs of an actual woman who's facing an unwanted pregnancy.


Regarding marriage equality and health care, the reality is this: Whether or not he or she acknowledges or is aware of it, every doctor has patients who are lesbian, gay, bisexual, or transgender, and sexual orientation affects health in many ways. The extent to which LGBT people are able to support their loved ones during illness is one of the most crucial.

The Human Rights Campaign ( an advocacy organization, publishes an annual survey rating hospitals and other health-care facilities on various aspects of their treatment of LGBT people: the safety, comfort, and satisfaction of LGBT people in health-care settings; whether LGBT patients are offered state-of-the-art medical care and information; equity for LGBT employees; and access to partners who are ill or hospitalized.

As a physician in a leading academic medical center located in Massachusetts, the first state to legalize same-sex marriage, I like to think that my own practice would fare well in such a survey. But, as we know from the civil rights and women' rights movements, the passage of laws and the best intentions of individuals don't eradicate centuries of deeply held prejudice overnight.


I can think of incidents in which I've been insensitive to the needs of LGBT people, not out of malice, but because I'd not developed the reflexes to consider them. Recently, I was writing a prescription for a woman I'd not met before and asked her how she could be so sure she wasn't pregnant if she wasn't using birth control. "Because I don't have sex with men," she answered, with appropriate exasperation.

Once, after I reviewed with a group of medical students how best to counsel patients about safe sex, a gay student expressed amazement that I'd all but omitted LGBT patients from my presentation.

But these gaffes, I think — I hope — are isolated. What worries me more is my failure to fully appreciate how prejudice colors some of my patients' experiences of the health-care system. For many years I've provided primary care for two women in their 70s who have lived together for decades. Perhaps because of the era in which they came of age, they'd never identified themselves to me as a couple, though it seemed clear that they were. They finished each other's sentences, took notes at each other's medical visits, and, when I called to discuss one of their test results, both got on the phone.

I sometimes wonder whether I should have encouraged them to be more open with me about the nature of their relationship, but I sensed this was not what they wanted. I'm still not sure I was right.


Once, one of the women became critically ill and required months of hospitalization outside of Boston. The other was at her bedside all day, every day. The doctor on the case called periodically to update me — progress was at times discouraging — and her companion also phoned regularly. She always left messages that began by identifying herself as the patient's "roommate" or "friend."

Eventually, because of excellent medical care and, no doubt, the "friend's" loving attentiveness, the patient recovered and was able to return home. When I got the call with this news, the message was slightly different: "This is her partner . . .," it began.

A small word, a subtle shift, and yet I couldn't help but read volumes into it. I imagined the woman, after months by her partner's side, after decades of denying their relationship, finally saying to herself, "Dammit, I've earned the right."

Of course I don't know for sure if that's what she said to herself. But I do know this: I receive dozens of phone messages every week, thousands every year — and I can't remember one that moved me more.

Dr. Suzanne Koven is a primary care
internist at Massachusetts General
Hospital. She writes a monthly column about the uncertainties, dilemmas, and stories that patients and doctors share in
practice. Read her blog on She can be reached at inpractice Her website: www