September 20, 2016

ORLANDO, Florida — The American Academy of Family Physicians (AAFP) has long grappled with how its members can both reflect and serve the diverse community that is the United States.

But there is still work to be done. In something as seemingly laudable as forbidding the purchase of sugary drinks with food stamps, family physicians were challenged by the issue of diversity — and the lack of sensitivity — here at the AAFP Congress of Delegates.

Yesterday, delegates discussed a resolution that called for removal of beverages sweetened with sugar or artificial substitutes from the list of products that recipients of food stamps — now known as the federal Supplemental Nutrition Assistance Program (SNAP) — can purchase.

Steering people away from empty calories toward nutritious food can reduce the incidence of obesity, diabetes, and heart disease, the argument goes.

One well-meaning delegate suggested that the ban ought to extend to candy, cookies, ice cream, and snack crackers, which are currently on the list of eligible SNAP products. That's when Shani Muhammad, MD, from California, walked to a microphone and called the resolution paternalistic — for starters.

"To tell someone what they can and can't do with their food choices because you pay for it is discriminatory," said Dr Muhammad. "It's offensive. It's potentially racist."

Although she said she does not want to encourage her patients to eat sugary foods, "it's more important for us as family physicians to educate our patients on how and why to make better choices than to be the voice that says, 'You have to, you have no choice'."

Other like-minded speakers said that nutrition will not improve for SNAP recipients until inner-city "food deserts" abound with sources of fruit, vegetables, and other nutritious fare. "Unless we address the real problem, we can't do this," said Tochi Iroku-Malize, MD, from New York.

"That Does Not Make Me...a Bigot"

Other resolutions debated yesterday — but not yet voted on — addressed the issue of diversity head-on.

For example, the creation of an Office of Diversity — which would work toward "nondiscrimination in education, training, and practice" — was proposed by the Colorado chapter of the AAFP. The office would support the development of antidiscrimination and hate-crime laws, as well as policies to protect "victims of scapegoating and/or discrimination targeted at their refugee, immigration, gender identity, race, color, religion, gender, sexual orientation, or disability status."

A number of delegates praised the resolution as a way for members of the AAFP and society at large to become purposeful and proactive in promoting nondiscrimination.

"We need something more concrete," said Adebowale Prest, MD, from Maryland. She said she has initiated conversations on the subject, as a woman of color, but they have gone nowhere. "Sometimes I feel like a broken record. Sometimes I feel like you do not hear me," she pointed out.

Concerns that an Office of Diversity might squelch some forms of diversity were expressed by Jim Taylor, MD, president of the Louisiana Academy of Family Physicians.

"Creating an Office of Diversity sounds very good," he said, "but we probably should be aware of the danger of this thing becoming weaponized."

Dr Taylor explained that he treats almost all the categories of patients covered in the resolution, including undocumented immigrants. "I can treat that person as a human being and still advocate that people here illegally should not be here," he said. "That does not make me a scapegoat or a bigot."

He said he would be "very concerned" if the Office of Diversity turned him "into a minority."

We need to discuss this without calling each other names.

For a resolution urging the AAFP to condemn xenophobia directed at "new immigrants," Dr Taylor voiced the same worries. Supporters of immigration security, like him, should not be labeled xenophobes, he said. "We need to discuss this without calling each other names."

But the resolution against xenophobia struck some delegates as too political during a presidential campaign in which Republican nominee Donald Trump has promised to build a wall between the United States and Mexico and order the mass deportation of "illegals." These delegates believe the AAFP should not make any pronouncement that seems to favor one party over the other.

Jim Gill, MD, from Delaware, said he understands concerns about the appearance of partisanship. However, he pointed out, the Congress of Delegates should support the resolution while the issue of immigration commands center stage. "If now is not the time to make a statement about what we say we believe in, when is?"

Standing Up for Transgender Patients

With three other resolutions, the discussion about diversity narrowed to sexual orientation and gender identity.

One calls on the AAFP to issue a "strong statement" condemning discrimination against gay, lesbian, bisexual, transgender, and queer (GLBTQ) people and to disseminate it to news outlets.

Two other resolutions seek to protect transgender people from discrimination and to secure their right, in particular, to use public facilities, including bathrooms, of their choice. The resolutions address state laws, like the one in North Carolina, that force transgender people to use bathrooms corresponding to their sex at birth.

"We are better than that," said Rhett Brown, MD, president of the North Carolina Academy of Family Physicians.

Some delegates testified that the AAFP already is on record opposing discrimination on the basis of sexual orientation and gender identity. Other delegates stressed the need for higher-profile declarations.

The resolution on transgender people using public facilities was sponsored by the Washington Academy of Family Physicians. Tony Butruille, MD, a member of that delegation, said his research on the transgender community has given him a greater appreciation for "how unrecognized, how unprotected they are and, because of the discrimination they face routinely, the poor outcomes they are susceptible to, both physical and mental."

"It's important for medical societies to weigh in on this," Dr Butruille said. "If you're against discrimination, you're against it in all forms."

Delegates broke out in applause.

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