Introduction

1. Introduction

2. Invisible Minorities • People who experience barriers to healthcare may be members of visible minority groups as in the case of racial and ethnic barriers, or invisible minority groups as in the case of uninsured individuals or gay, lesbian, bisexual, transgender, or intersex individuals.

3. Sexual Orientation/Gender Identity • Sexual orientation- considered to have three dimensions. 1. Desire/attraction 2. Behavior 3. Identity • Gender – the emotional and psychological characteristics that classify an individual as female, male, both or neither. Includes both individual conceptions (gender identity) and societal components (sex roles). • Sex – physiological characteristics and biology which are used to classify female, male, intersex, or neither.

4. What Is a Sexual Minority? • Gay/gay man- a man who is attracted to and/or forms intimate relationships with other men. • Lesbian- a woman who is attracted to and/or forms intimate relationships with other women. • Bisexual- an individual who is attracted to and/or forms intimate relationships with men and women.

5. What is a Sexual Minority? • Trangendered- an individual who lives either part or full time as a member of the opposite gender. These individuals may be heterosexual, homosexual, or bisexual. This includes transvestites (cross-dressers) and transsexuals (those who choose to live as the opposite gender of his/her genetic sex at birth, independent of whether he/she undergoes sex reassignment surgery). • Intersex- individuals with medically established physical or hormonal attributes of both the male and female gender. These conditions include androgen insensitivity syndrome and congenital adrenal hyperplasia.

6. Prevalence of Sexual Minorities • In the 2000 Census, same-sex partner households were documented in unprecedented numbers in every state and in all but 22 counties in the U.S. • This number still vastly underestimates the number of LGBTI individuals because it does not include single homosexuals. It also fails to characterize transgender or intersex people who may be heterosexual, bisexual, or homosexual. • http://www.ngltf.org/issues/census2000.htm

7. LGBTI Barriers to Health Care

8. Think! • How many barriers to care for LGBTI individuals can you think of?

9. LGBTI Barriers to Health Care • Bias/ignorance/phobia of provider • Exclusion of partner in health care decisions • Heterosexist assumptions on forms/interviews • Lack of coverage under partner’s health plan • Fear of being “outed” to employers, insurers, etc. • Lack of provider knowledge about health care risks/issues for LGBTI individuals • Patient’s own internalized homophobia • Lower SES

10. Provider Bias • 25% of 2nd year medical students in a survey done in 1999 thought homosexuality was “immoral and dangerous to the institution of the family” • Journal of Homosexuality 37(1):53-63, 1999

11. Providers’ Lack of Education • Over half of all medical schools offer no training on LGBTI health issues with the remainder providing an average of 2.5 hours of education regarding LGBTI issues in the 4 year program. • http://books.nap.edu/books/0309060931/html/index.html p. 43. • Family Medicine 1998, 30 (4) 283-287.

12. Inappropriate Behavior By Providers • Respondents to a survey by the Gay and Lesbian Medical Association (1994) reported having seen doctors perform “rough” or “violent” digital rectal exams on patients the doctor knew to be gay. • http://www.glma.org/policy/hp2010/index.html p. 128

13. Biases in Health Care Forms/Interviews • Do the forms in your medical clinics have boxes that only offer the choices single/ married/ widowed/ divorced? • When a female patient says that she is sexually active, is the next question automatically “What are you using for birth control?” • Are the only choices on your forms under gender male or female?

14. Legal Barriers to AppropriateHealth Care • Denial of spousal benefits to unmarried partners • Blood relatives may override health care decisions of same-sex partner unless couple has health proxy/ durable power of attorney • Hospitals may limit visitation to blood relatives or spouses • LGBTI people may be wary to seek health care where sodomy laws still apply. (14 states, Puerto Rico, the military) http://www.sodomylaws.org/usa/usa.htm

15. The Evidence

16. Hate Crimes • Anti-LGBTI hate crimes are prevalent throughout the U.S. (2,210 reported to the National Coalition of Anti-Violence Programs in 2001) • Many states do not protect those who are assaulted because of their sexual orientation/ gender identity.

17. Lack of Health Insurance • Even though lesbians and bisexual women are more likely to have attended graduate school and work in managerial positions, they lack health insurance at a higher rate than heterosexual women (6.8%-hetero, 9.7-10.4%-lesbian, 12%-bisexual). • Archives of Family Medicine 2000, 9, 843-853. • Rates of the uninsured are even higher among transgender population ranging from 21-48%. • http://www.glma.org/policy/hp2010/index.html p. 50

18. Lesbian Obesity • Lesbians have a higher BMI than heterosexual women, including heterosexual women in their own families (i.e. sisters). • Psychological Science 2001, 12 (1), 63-69. • Lesbians consume fewer fresh fruits and vegetables than heterosexual women. • Archives of Family Medicine 2000, 9, 843-853. • These factors may increase their risk for cardiovascular diseases and cancers. • http://www.glma.org/policy/hp2010/index.html p. 244.

19. Lesbians and Breast Cancer • Although definitive research has not been done, lesbians are believed to be at higher risk of breast cancer than other women due to confirmed higher rates of risk factors: • Obesity • Alcohol Consumption • Nulliparity • Lower rates of breast cancer screening Am J Public Health 2001 Apr; 91(4):591-7

20. Lesbians and STDs • Although lesbians who have sex only with women are thought to be at relatively low risk for contracting syphilis, chlamydia, and gonorrhea, there is documented transmission of HPV and bacterial vaginosis (BV) between women. In fact, rates of BV are significantly higher in lesbians than in heterosexual women (18-36% vs. 16%). • http://books.nap.edu/books/0309060931/html/index.html p. 73.

21. Gays and Cancer • Gay and Bisexual men have higher rates of anal cancer (associated with HPV infection), non-Hodgkin’s lymphoma, and Hodgkin’s disease compared to heterosexual men. Further, their 5-year survival rate with non-Hodgkin’s lymphoma and Hodgkin’s disease is significantly reduced. • http://www.glma.org/policy/hp2010/index.html p. 102

22. Gay and Bisexual men with HIV • In a CDC study looking at HIV prevalence in 15-22 year old men who have sex with men (MSM), 7.2% were HIV positive, with even higher percentages for African-American and Hispanic MSM • http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5021a4.htm

23. It is important to ask about behavior and not just identity. Many men who have sex with men do not identify as gay or bisexual, yet they are still at risk for many STDs. • Because of this, many studies report incidence of disease in MSM rather than gay or bisexual men. • http://www.cdc.gov/mmwr/preview/mmwrhtml/00056314.htm • http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5007a2.htm

24. Mental Health • Gay men are 6 times as likely as heterosexual men to attempt suicide. Lesbians are twice as likely to attempt suicide compared to heterosexual women. • Death by Denial: Studies of Suicide in Gay and Lesbian Teens. 1994. Alyson Publications, 15-88. • 20-42% of LGBTI youth attempt suicide. • http://www.glma.org/policy/hp2010/index.html p.52

25. Mental Health: Eating Disorders • Homosexual boys are twice as likely to have a poor body image and disordered eating patterns in comparison with heterosexual boys. • International Journal of Eating Disorders 1996, 19, 119-126. • Homosexual girls, though almost twice as likely to report a positive body image compared to heterosexual girls, are still as likely to have disordered eating patterns. • International Journal of Eating Disorders 1997, 22,15-27. • http://www.glma.org/policy/hp2010/index.html p. 216.

26. Transgender Mental Health • In a recent study of transgendered people in San Francisco, 62% of the MTF (male to female) and 55% of the FTM (female to male) individuals were depressed and 32% of both groups had attempted suicide in the past. • Am J Public Health 2001 Jun;91(6):915-21 • Transgender individuals are also at risk for self-mutilation, with 9% of males attempting self-castration and 2% of females attempting breast mutilation. • Archives of Sexual Behavior 1984, 13, 269-277. • http://www.glma.org/policy/hp2010/index.html p.216.

27. Transgender Hormone Usage • 29-63% of urban MTF transsexuals use black market hormones. • Transgender patients must undergo expensive psychological evaluations before getting prescribed hormones at many clinics. • Because many transgender patients cannot afford these evaluations, they often get black market hormones instead, which may be adulterated or unsafe. • http://www.glma.org/policy/hp2010/index.html p.47

28. HIV in Transgender Populations • MTF transsexuals have extremely high rates of HIV infection, ranging from 22-47% in some urban populations. These rates are even higher among African-American MTFs. • http://www.glma.org/policy/hp2010/index.html p. 184

29. Intersex Issues • Intersex individuals, born with congenital anomalies of the reproductive and sexual systems, often have multiple surgeries in infancy to “assign” gender (usually the default is creating female external genitals). These surgeries continue to occur despite the acknowledged inability to predict a child’s gender identity. • http://www.aap.org/policy/re9958.html • http://www.isna.org/library/dreger-ambivalent.html

30. Post-surgical Complications for Intersex People • Though clitoral reduction has been commonly performed on infant girls with genital masculinization, it is not without its problems. Adult intersex women who had surgery have greater problems with sexual function compared to intersex women who had not undergone surgery. 25% of the surgically treated intersex women were unable to reach orgasm. • Lancet 357, 2001, p. 2110. • www.lancet.com

31. Youth at Risk • Bisexual and lesbian adolescent females have twice the prevalence of pregnancy compared to heterosexual teens. • LGBTI high school students have been threatened with a weapon at a rate four times that of heterosexual high school students. • While 10% of heterosexual teens reported attempted suicide, 40% of LGBTI teens reported suicide attempts. • http://www.siecus.org/pubs/fact/fact0013.html

32. Looking at Your Beliefs

33. The Heterosexist Challenge • The following exercise looks at your personal beliefs regarding sexual identity and explores whether you view the world as a place where everyone is, or should be, heterosexual. • http://www.amsa.org/adv/LGBTIpm/challenge.cfm

34. Think! • Do your beliefs about sexuality and gender identity negatively affect the health care you provide for your patients? • Do you feel that you know the health care needs of LGBTI patients?

35. Think! • What can you do to improve health care access and servicesfor LGBTI individuals in your community?

36. Action Points

37. Allies • If you’re not LGBTI yourself, become an ally. • http://www.hrc.org/ncop/allies/print.asp • http://dislecksea.home.mindspring.com/sbnn.html

38. Learn About Specific Health Care Needs of LGBTI Individuals Ten Things Health Care Providers should Discuss with their Gay or Bisexual Male Patients 1. HIV/AIDS, Safe sex 6. Prostate/Testicular/Colon cancer 2. Substance Use 7. Alcohol 3. Depression/Anxiety 8. Tobacco 4. Hepatitis Immunization 9. Fitness (Diet and Exercise) 5. STDs 10. Anal Papilloma • All men who have sex with men should be vaccinated for Hepatitis A and Hepatitis B. • http://www.glma.org/news/releases/n02071710gaythings.html

39. Learn about specific health care needs of LGBTI individuals Ten Things Health Care Providers should Discuss with their Lesbian and Bisexual Female Patients 1. Breast Cancer 6. Tobacco 2. Depression/ Anxiety 7. Alcohol 3. Gynecological Cancer 8. Domestic Violence 4. Fitness (Diet and Exercise) 9. Osteoporosis 5. Substance Use 10. Heart Health • http://www.glma.org/news/releases/n02071710lesbianthings.html

41. Learn About Specific Health Care Needs of LGBTI Individuals • Learn where to find health information for gay and bisexual men • http://www.metrokc.gov/health/glbt/gbmen.htm • Learn where to find information for lesbian and bisexual women. • http://www.metrokc.gov/health/glbt/lbwomen.htm

42. Learn about specific health care needs of LGBTI individuals • Learn the basics about Transgenderism in: “Hot Seat Questions about Transgendered People” • www.gender.org/resources/dge/gea01002.pdf • Basic Tips for Healthcare and Social Service Providers working with Transgendered People • http://www.gender.org/resources/dge/gea01006.pdf

43. Learn about Medical Complications of Transgender Hormone Use • MTF hormone use (estrogen/progesterone) increases the risk of venous thromboembolism, infertility, weight gain, emotional lability, liver disease, and benign pituitary tumors. • FTM hormone use (testosterone) increases cholesterol and lipid levels, and risks of MI, mood changes, liver disease, male pattern baldness, and acne. • Journal of the Gay and Lesbian Medical Association 2000, 4(3), 101-151.

44. Learn about specific health care needs of LGBTI individuals • Intersex Society of North America’s Recommendations for Treatment • http://www.isna.org/library/recommendations.html • The American Academy of Pediatrics recommends when deciding the sex of rearing of a baby with ambiguous genitalia, one should consider fertility potential, capacity for normal sexual function, endocrine function, potential for malignant change, testosterone imprinting, and timing of surgery. • www.aap.org/policy/re9958.html

45. You can talk to youth about sexual identity/behavior • Teens often have few people to talk to about LGBTI issues • 61% of parents would discuss homosexuality with their children if asked, but would not bring up the subject on their own. • While half of gay/lesbian adolescents reported discussions of homosexuality in their classrooms, 50% of females and 37% of males reported it being discussed negatively. • So, if health care providers don’t talk to these teens about LGBTI issues, who will? • http://www.siecus.org/pubs/fact/fact0013.html

46. Provide Inclusive Forms and Sensitive, Competent Care for Your Patients • Instead of boxes for gender, have a blank line where patients can identify themselves as they choose, not in the rigid categories that you choose for them. (e.g. Most intersex individuals prefer to identify as intersex v. male or female, and trans individuals may identify as MTF, FTM, trans, or as male or female). • When asking about sexual behavior, ask “are you sexually active with men, women, or both?” And then, only if appropriate, ask about birth control. • Ask all your patients about domestic violence using the terms “partner, family member, or caretaker” instead of “boyfriend or husband”.

47. Provide Inclusive Forms and Sensitive, Competent Care for Your Patients • When treating a transgendered individual, use the pronoun appropriate to the gender of their choice, not their birth gender. • If unsure, always ask your patients what they prefer. • Don’t make assumptions about your patients based on their stated gender or sexual identity. • Use gender-neutral language(e.g. partner, significant other). • Encourage your patients to include their family of choice in their health care.

48. Talk to your Patients about Legal Documents • It is important for LGBTI individuals who have non-traditional family structures to consider their current and future legal needs, especially regarding healthcare. • Often times, this may include the need for hospital visitation rights, durable power of attorney, living will, co-parenting agreement or second parent adoption. • You can help your patients by being knowledgeable about these documents, and/or referring your patients to appropriate legal counsel. • http://www.lambdalegal.org/cgi-bin/iowa/documents/record?record=120

49. Resources • http://www.gayhealth.org Gay Health is the first health and wellness website dedicated to lesbian, gay, bisexual and transgender men and women. • http://www.LGBThealth.org The Gay, Lesbian Bisexual, and Transgender Health Access Project from the Massachusetts Department of Public Health wants to foster the development of comprehensive, culturally appropriate health promotion policies and health care services for LGBTI people. • http://www.metrokc.gov/health/GLBT Web pages which address the health concerns of the LGBTI community. • http://www.glma.org The Gay and Lesbian Medical Association exists to maximize health care for LGBTI individuals.

50. Resources • http://www.gender.org Gender Education and Advocacy is a national organization focused on the needs, issues, and concerns of gender variant people in human society. • http://www.gpac.org The Gender Public Advocacy Coalition works to end discrimination and violence caused by gender stereotypes. • http://www.isna.org The Intersex Society of North America is devoted to systemic change to end shame, secrecy, and unwanted genital surgeries for people born with an anatomy that someone decided is not standard for male or female. • http://www.hbigda.org The Harry Benjamin International Gender Dysphoria Association is a professional organization devoted to the understanding and treatment of gender identity disorders.