Whether one regards homosexuality as a legitimate lifestyle, an aberration determined by genes or environment or an unforgivable sin, everyone would agree that lesbians, gays, bisexuals and transgenders (LGBT) deserve the same high level of health care as the "straights." But how do you achieve this? In countries such as the US that lack universal health insurance, LGBTs - who are often employed in low-status or low-paying jobs - are less likely to have medical coverage. And in countries with a guaranteed basket of health services for all residents, such as Israel, they may either be unable to find a clinic suited to their unique health needs, be too reluctant to speak about them or unwilling to be treated by homophobic doctors whose personal values clash with their professional responsibilities. A conference on "Gay Health" was held during the first week of August in Jerusalem - which was to have been the site of a highly controversial International Gay Parade, cancelled due to the war in Lebanon. The sponsors were the New Israel Fund, the Pfizer pharmaceutical company and Manhattan's Callen-Lorde Community Health Clinic; it was organized by the Jerusalem Open House for Pride and Tolerance - a non-profit grassroots activist center on Jerusalem's Ben-Yehuda Street that describes itself as "one of the Middle East's leading LGBT service and advocacy organizations. The 100-seat hall in the Konrad Adenauer Conference Center at Mishkenot Sha'ananaim was surprisingly half-empty at the beginning of the all-day, English-language event, although it began to fill up (with foreigners who came to attend World Pride events and some local doctors, as well as Israeli LGBTs) by noon. But the discussions were thought provoking, opening a window on a subject that the "normative" population rarely thinks about. Jay Laudato, executive director of the Callen-Lorde clinic and a self-declared homosexual, described the difficulties faced by LGBTs in New York. His licensed center, located in a seven-storey building in Manhattan's "gay neighborhood," was founded in 1983 as a community health project consisting of two clinics manned by volunteer physicians to treat sexually transmitted diseases. It gradually broadened its focus to include transgenders, homosexuals and bisexuals. "There were many runaway and 'throwaway' kids in the area who came to us as a haven. They quickly became involved in the local sex trade," Laudato recalled. As the prevalence of AIDS surged, the facility became the first designated HIV clinic in New York. The two people in whose memory the clinic was named were Michael Callen, a homosexual activist who died in 1993 at 38 and Audre Lorde , a black woman and lesbian activist who served as poet laureate of New York State and died at the age of 61 a year before Callen. The Manhattan clinic is one of only eight in the US, he said. THE KEY ISSUES, said Laudato, were access of LGBTs to medical institutions and primary care, health disparities and the medical delivery system. He noted that while a quarter of all American physicians are trained in New York, and 70 hospitals exist in the five boroughs of the city, the Callen-Lorde Clinic has 40,000 registered patients who go there instead of to conventional facilities. Today, as the largest freestanding HIV center in New York, it also offers a wide variety of primary care, including gynecological health care for lesbians, urgent care, a sexual health clinic, mental health and dentistry. A survey of its patients found that a third are women, 87 percent are under 40, 48% are white, 24% African American, 23% Latino and 3% Asian or Pacific Islanders. HIV testing and treatment are the most frequently used services, but others are transgender hormone care (hormones must be taken on a lifelong basis by people who have had a surgical sex change, and these drugs can cause complications affecting the liver and other organs); genital wart treatment (such growths can turn into cervical cancer); diabetes, vaccinations (such as for hepatitis B); hypertension; and preventive care. Although there are conditions and needs unique to LGBTs, he added, the clinic's clientele also "have routine health problems that everybody has. The clinic automatically tests the blood pressure of everyone who comes in for treatment of sexually transmitted diseases, for example, to detect hypertension at an early stage...We have the same bodies, teeth and eyes, but we have more disease from disparities in health care due to living in homophobic communities." While LGBTs tend to work in lower-paying and untenured jobs that lack health insurance as a bonus, others suffer because their partners are not recognized as spouses by health maintenance organizations that do insure homosexual and lesbian employees. Callen-Lorde itself, Laudato admitted, couldn't afford to provide health insurance for the partners of its own staffers or the children of partners, as the insurance premium would be more than the clinic's mortgage payments. A patient survey found that 74% felt they had been discriminated against by the regular health system, and 24% withheld information about their sexual practices from doctors in the regular medical system (compared to 5% of heterosexuals). As a result of provider bias, Laudato continued, some homophobic physicians refuse to treat patients, or may fail to take an appropriate medical history. Homosexuals, whether they are men or women, are much more likely than heterosexuals to smoke, drink and take other drugs. Lesbians are less likely to have children, thus they are at higher risk of breast cancer. Lesbians are also at higher risk of depression and anxiety than their "straight" counterparts, and are also more prone to eating disorders, osteoporosis, obesity and cardiovascular diseases, while male homosexuals are of course at higher risk of HIV/AIDS, but also of alcoholism, depression, diseases from tobacco consumption and taking steroids. "And I have yet to meet a transgender who doesn't smoke," Laudato added. A FREQUENT complaint in the LGBT community is that medical research doesn't consider sexual identity, so many studies are not relevant to their health. "We have to educate medical schools and health insurance providers." The clinic is affiliated with medical schools, but residents spend only short periods studying LGBT medical care there because the clinic isn't paid for it and supervision is very expensive. "We hope there will be a time when clinics like ours are no longer necessary because giving LGBTs equal treatment and sensitivity will be the norm," Laudato concluded. Canada has a universal health insurance system, as does Israel, thus LGBTs there do not have to go without medical care, said Todd Ross, director of strategy outreach to Ontario's minister of health and long-term care, George Smitherman. Both the minister and Ross are openly gay, as is a former mayor of Winnepeg. "Toronto has a large LGBT community, and Canada's is the third largest in the world. As a result, Toronto is a "tolerant place for LGT people and doctors, whom we actively recruit." Toronto was chosen as the venue for the 16th International AIDS Conference, attended by tens of thousands, including 3,000 journalists, last week. Ross described the unusual cooperation between the Sherbourne Health Center for LGBTs and the nearby St. Michael's Catholic Hospital, which was expected to be extremely hostile to homosexuals. "The previous government said there were too many hospitals in the area, so it decided to close some and open others in faraway places. One medical center in the city's downtown gay neighborhood was shut down, and St. Michael's was designated to treat them. "We expected hostility, but they actually did a terrific job and appointed an advisory board from the LGBT community." Dr. Sagit Arbel-Alon, a gynecologist at Hadassah University Medical Center's Women's Health Center in Jerusalem's Ein Kerem surprised participants when she announced that in mid-September, it will be the first in the country to offer medical services specially for lesbians. The announcement was not made by Hadassah Medical Organization management, and this reporter was told it is "not a lesbian health center" but a place whose staff will offer sensitivity, and have special training to provide services to lesbians. Arbel-Alon noted that many lesbians neglect their health because they are deterred from revealing their sexual practices to their doctors and thus stay away, avoiding tests and treatment. Although there won't be a separate sign outside the Women's Health Center or a "segregated" waiting room, the facility will offer medical questionnaires suited to this clientele, different terminology and more sensitivity. "I can't speak for all gynecologists, but I know that many of them believe there is no need to do a Pap smear for cervical cancer on women who have sex solely with women. But the scientific literature shows there is no difference in the prevalence of papilloma virus (which causes cervical cancer) between lesbian women and heterosexual women." In any case, Arbel-Alon believes that many lesbians will come to Hadassah from around the country to benefit from discreet and sensitive care. It will be interesting to see whether other hospitals around the country copy the idea.