SGM health, medical care, and tips

1. SGM health, medical care, and tips Jane McElroy, PhD Family and Community Medicine Department Struby Struble LGBTQ Resource Center August 07, 2012 Acknowledgment to GLMA, Fenway Institute, Lamda Legal for assistance with content and slides

2. Learning objectivesfor Sexual and Gender Minority (SGM) • Define terminology and describe concepts associated with SGM populations 2. Describe the ways in which marginalization and discrimination impact the health of SGM people 3. Discuss the health disparities experienced by SGM people

3. Basic Terminology: LGBT LGBT umbrella term to describe all sexual and gender minorities, new term (SGM) Diversity within each group Race and ethnicity SES Geographic location Age Lesbian Gay men Bisexuals Transgender

4. GENDER • Gender is different from sex (determined by chromosomes and anatomy) and different from sexual orientation • Gender Identity – The psychological awareness or sense of where one fits on the man‐woman spectrum • Gender Expression – The way in which one communicates his or her gender identity through appearance and behavior • Gender Role – That part of behavior that is influenced by society’s expectation of what is gender‐appropriate

5. Transgender Transgender, Gender Variant, Gender Non‐Conforming, Gender Different • Umbrella terms used to group the many gender different communities • A person whose gender identity or gender expression differs from the sex assigned to them at birth

6. Transgender Transsexual • Biological men and women whose gender identity most closely matches the other gender • “Transsexual” is sometimes used more specifically to specifically describe transgender people who have undergone genital surgery

7. Transgender Genderqueer– Used to describe people whose gender identity does not fit neatly into either male or female categories Crossdresser– Individuals with a desire to wear the clothing of the other sex but not to change their gender; many are heterosexual men who crossdress for erotic arousal; previously called transvestite Drag Queen/King – Individuals, usually in the gay/lesbian community, who crossdress for entertainment purposes and/or to challenge social stereotypes

8. Sexual Orientation“Are you gay or straight?” • It’s not that simple! • Behavior ≠ identity ≠ orientation

9. Sexual Orientation Sexual Attraction • Who you are attracted to in your sexual fantasy life (e.g.heterosexual, homosexual, bisexual) • An internal identity; you only know your own for sure • Develops very early and is not a choice • Also called “Orientation” • Sexual Behavior • Who you choose to have sex with • Can be aligned with Sexual Attraction, or not

10. Sexual Orientation Sexual Identity • A label you choose to call yourself in order to tell others what you want them to understand about your sexual orientation (e.g. straight, gay, bi, lesbian, dyke, etc.) • May include emotional, social & lifestyle preferences • Can be reflective of your Sexual Attraction and Sexual Behavior, or not

11. A combination of Traits CAH: congenital adrenal hyperplasia

12. Sexual Orientation US Prevalence • Exact prevalence remains unknown • Measurements vary widely by geography, • Race/ethnicity, education levels, suggesting strong influence of stigma The Social Organization of Sexuality (Laumann, 1994)

13. Transgender Prevalence No reliable data: • 1:500‐1:2000 TG identity1 0.002% • 1:2000 TG hormones (Belgium) • 1:2900 MtF surgery/hormones (Singapore) • 1:11900 MtF surgery/hormones (Netherlands) • 1:30400 FtM surgery/hormones (Netherlands) • 1:30000 MtF surgery (USA) 0.00003%

14. Transgender (for this talk) Patients are those who transition fulltime to a sex/gender other than the one on their birth certificate, FtM or MtF • Transitioning very intensive process • Much thought, discussion, counseling • Usually hormones, sometimes surgeries • Guidance from WPATH, UCSF, Endocrine Society • Increasingly covered by insurance, per AMA • Yet, transgender people can encounter serious bias, in health care and beyond

15. Disparities in SGM Health Among SGM people • 75% been verbally abused • 32% have been the target of physical violence • 34% have been rejected by their families Among transgender people • 57% have been rejected by their families • 26% have been fired • 19% have been refused housing Source: Kaiser Family Foundation, National Center for Transgender Equality

16. Barriers to Care--Fears…. “I will be refused medical service because I am … Source, “When Health Care Isn’t Caring” (Lambda Legal, 2010)

17. Barriers to Care---delays % Adults receiving ER care Source: California Health Interview Survey (CHIS), 2007

18. Barriers to Care---Fears “Medical personnel will treat me differently because I am…” Source, “When Health Care Isn’t Caring” (Lambda Legal, 2010)

19. What does “Different” Treatment mean • 56% of SGM patients & 70% Transgender patients reported at least one of the following health care experiences, based on SGM status • Being blamed for their health condition • Refusal to touch or excessive precautions • Harsh language • Physical roughness • Numbers were much higher for SGM racial/ethnic minorities and low-income SGM individuals Source, “When Health Care Isn’t Caring” (Lambda Legal, 2010)

20. Additional experiences • Right after patient comes out, health care provider • Walked out or shortened interview • Expressed surprise, embarrassment or confusion • Stereotyping---a couple of examples • Over-focus on HIV with gay men • Belief that lesbians don’t need paps

21. Additional experiences of Transgender patients • Elongated wait time • Confidentiality violations • Staff coming by “to take a look” • Unnecessary or repetitive questions and exams • Use of wrong gender/name, accidentally or deliberately • Mocking comments, expressions of disgust, etc • Denied or questioned bathroom use

22. Healthcare Provider Attitudes—improving with time but still unacceptable high Physician Attitudes Would discontinue referrals to a gay pediatrician Uncomfortable providing care to gay patients Sources: Matthews (1986); Smith and Matthews (2007)

23. But if Lesbians who are out to the PCP Statistically significantly more likely to Seek health and preventive care Have a pap test Not smoke Discuss difficult issues Source: White & Dull, 1998

24. SGM Clinical Concerns—tobacco use • SGM twice as likely to smoke cigarettes than heterosexuals (McElroy et al, 2011) • 38-59% SGM youths smoke vs 28-35% hetero youth (Ryan et al, 2001) • Estimated 30,000 SGM patients die each year from tobacco-related diseases (ACS, 2003)

25. SGM Clinical Concerns--weight • Lesbians 2x as likely being overweight or obese (Boehmer, 2007; Roberts, 2003) • Eating habits among lesbians may be less healthy (Valanis, 2000) However, addressing fitness vs losing weight may be more helpful strategy

26. SGM Clinical Concerns—eating disorder • Gay and bisexual men have higher prevalence of eating disorders compared to hetero men (Feldman & Meyer, 2007) and higher body dissatisfaction (Kaminski, 2005) • Younger SGM men (18-29 years) at higher risk (Feldman & Meyer, 2007)

27. SGM Clinical Concerns---CVD Gay and Bisexual men’s risk factors • Cigarette smoking • Use of club drugs, anabolic steroids (linked to HPN) • HIV-infected individuals’ use of HAART (associated with increase incidence of dyslipidemia, insulin resistance, type II diabetes) Lesbian and Bisexual women’s risk factors • Smoking • Obesity/being overweight Transgender patient’s risk factors • Use of estrogen or testosterone may increase risk (Biller, 1995) but evidence is indeterminate

28. SGM Clinical Concerns—Cervical Cancer • Lesbians get Pap tests less frequently than hetero • Fewer paps last year (61% vs 74%, Diamant, 2000) • Fewer annual paps (49% vs 66%, Matthews, 2004) • Lesbians are at risk for cervical cancer • 77.3% have had sex with men (Diamant, 1999) • Women to women HPV transmission occurs (19% in lesbians who have never had sexual contact with men, Marrazzo, 1998)

29. SGM Clinical Concerns—Breast cancer • Lesbian and bisexual (LB) women up to 4x less likely to get mammograms (Kerker, 2006) • LB may have more risk factors for breast cancer • Obesity, alcohol use, smoking, lower rates of parity • Cross-gender hormone therapy used by MtF may increase breast cancer (Schlatterer, 1998)

30. SGM Clinical Concerns—Anal Cancer • Incidence of anal cancer estimated 80x higher in gay men than hetero (Knight, 2004) • HIV-infected gay or bisexual men at increased risk (Friedman, 1998) • Men who have receptive anal intercourse and multiple partners at highest risk (Chin-Hong, 2005)

31. SGM Clinical Concerns—Mental health • Homosexuality is not a mental illness (removed from DSM in 1973) but Transgender still is (Gender identity disorder—plans to change DSM-V to “Gender Dysphoria) • SGM patients may be increased risk for • Depression (Cochran, 2003) • Anxiety and panic attacks (Cochran, 2003) • Suicidal behavior, esp adolescents (Silenzio, 2007) • Eating and body image disorders (men) (Siever, 1994; Kaminski, 2005) • Transgender women (MtF) at high risk for • Suicidal thoughts, attempts (Herbst, 2008)

32. Out, Proud and Healthy StudyMU research—local research MISSOURI 2011 Pride Festivals Adult Participants N=1033 N= 465 N=2003 N=218 Total=4041 Web: N=322

33. Key findings: Health Risks compared to MO population • 2 times more likely to smoke but 5 times more likely to be occasional smokerand for college educated, 2.5 times more likely to smoke • 2 times more likely to be risky alcohol user • Slightly less likely to eat healthy • 3 times more likely to reported depressive symptoms

34. Key findings: SGM Health accesscompared to MO population • ~1.5 times less likely to have health insurance • 2 times more likely NOT get medical or surgical txmtincluding for 65+ SGM year olds • 3 times more likely to take lessmedication

35. What can a doctor do?

36. Avoid Assumptions • Don’t Assume • All patients are heterosexual • All patients use traditional labels • Sexual orientation based on appearance • Sexual identity based on behavior (or partner’s gender) • Sexual behavior based on sexual identity • Sexual behavior or identity haven’t changed since last visit • Bisexual identity is only a phase • Transgender patients are gay, bisexual or lesbians

37. Tips For Interacting with SGM Patients • Don’t trust your gaydar (or transdar): anyone can be SGM, regardless of appearance • Create forms that allow patients to come out easily • Offer partner or significant other option • Offer a way for transgender patient to self-identify and give a preferred name • Consider asking about sexual orientation

38. Tips For Interacting with Transgender Patients • As a rule, gender and name given by patient should be honored • If unsure about preferred gender or name, ask privately and gently—don’t guess • Know that each patient approaches transition in the way that is right for them---one size does not fit all, especially around surgeries • Approach exams and screenings sensitively

39. Tips For Interacting with SGM Patients • Help patients come out to you in person • Take personal displays of affections (PDAs) in stride • Use “partner” instead of “husband” or “wife” • Ask about “family” instead of “mom” or “dad” • Use SGM patient’s language back to them • Ask about sexual activity open-endedly and comfortably

40. After a patient comes out to you • Practice how you will respond---a smile and warm acknowledgement makes such a difference! “Thank you for sharing that---I know it is not always easy. Is there anything you’d like to talk about in that connection?” • Use SGM patient’s language back to them • Ask about unfamiliar terms (that matter) • Don’t worry about making good faith mistakes--asking well-meaning questions, or not knowing it all

41. A few more tips • Decorate your office: SGM brochures, photos, pins, flags to create a welcoming environment • Arrange and offer SMG cultural competency training (especially include your front line staff) • Support your SGM colleagues • Do SGM research • Join in SGM individuals achieving • Nondiscrimination protection • Equal health benefits for partners • Transgender insurance coverage

42. Thank you Questions?