If HIV and breast cancer weren't threatening enough, gays are hit with poor medical care - unless we find gay-knowledgeable & gay-friendly health providers. The figures otherwise describe a brutal bottom line.

The problems starts with us. In studies done in 1990 typically 3/4 of lesbians and 1/2 of gay men do not identify sexual orientation to doctors. One-half of gay men with HIV do not reveal this to their attending physician.

Nearly all of those who don't tell feel they would get inferior care if they did. Many report abusive reactions when they do.

The problem is compounded by health providers. If we do come out, we risk getting the booby prize: poor care. In 1990s studies of general practitioners, typically only 1/3 feel comfortable with gay men. Doctors are conservative; over 1/3 thought we should not work in schools and that homosexuality is "just plain wrong" while 2/3 felt that gays should not be recognized as normal.

Homo-ignorance is also a problem. Only 1/10th to 1/3 of primary care doctors routinely take a sexual history; fewer than that even think to ask about sexual orientation.

This potential for injury is compounded by closeted figures - leaving our physicians working in the dark. Up until AIDS, authorities of all types - medical, legislative, administrative - have not seen fit to tabulate even our ills, not just the crimes against us. Lesbians by far suffer the most from statistical silence or underreporting. Without figures we don't know the extent of the lesbian breast cancer problem nor the gay male anal cancer problem. Delayed diagnoses means poor prevention - and can mean death orneedlessly extended, expensive repair.

Gays on the inside - 2/3 of Gay and Lesbian Medical Association members - believe gays receive substandard care. Over half have seen medical peers reducing care or denying care to patients because they were gay.

Don't ask/don't tell in health care means poor medical care. For example, many gynecologists assume that lack of heterosexual intercourse eliminates women's health problems - including breast cancer - when in fact it makes them worse.

In the 90s we face a further challenge: managed care. In but a few years most of us are being forced into insurance plans where gay doctors no longer exist - no prepaid health plan recognizes gay health as an area of specialization or identifies gay-friendly doctors. This is truly dark-ages medicine for gays - where we and our gay-specific dangers don't even exist.

Even with AIDS, a high-profile well-defined area of practice, gays outside major metropolitan areas find themselves in the hands of doctors ignorant or inexperienced with AIDS - much less with the wide variety of other gay-specific health problems and practices. This makes the prognosis for gay health in the 90s very poor indeed.

Gay doctors have been further handicapped by the medical profession's discrimination against its own gay members. The AMA has turned down three times in three years a proposal to add sexual orientation to the nondiscrimination policy in the Association's bylaws. For example, half of all orthopedic surgeons feel that a highly qualified gay or lesbian applicant should not be admitted to medical school.

Nearly 2/3 of Gay Medical Association members report discrimination, harassment, or ostracism. This handicaps gay providers since good health care depends increasingly on quality referrals and teamwork.

The costs of the present "don't ask/don't tell" situation are untenable. People with AIDS have much to teach here. Heed their lessons.

Let's come out explicitly to our health care providers. Shop critically for physicians - researching, interviewing, and evaluating them. This means explaining in detail what we do physically in gay sex so physicians can know what to monitor, what to prevent, and what to diagnose. There's little in life that's more physical than sex - and that's also why they're called physicians.

A bonus in all this may be a decrease of inner homophobia and an increase in our ability to talk about sex with each other. Gay pride starts with not downplaying the physical side of gay sex. Yes, gay life still takes place between the sheets - not just in the streets.

We can expect few health providers to be expert on sexual orientation issues and how they impact our health. Result? We need to become our own experts in this area. This also means choosing physicians who are comfortable in sharing information and mutual decision-making.

If we grapple with these issues and finally find and hire gay-knowledgeable & gay-friendly providers to help us manage them, we'll overcome this formidable challenge to being both financially and physically gay-healthy.