LGBTQ Health : Who, What, Where and Why We Should Care

1. LGBTQ Health: Who, What, Where and Why We Should Care Laura C. Hein PhD, RN, FAAN

2. Objectives • Introduce you to LGBTQ terminology • Discuss historical and contemporary health concerns of the LGBTQ community • Discuss facilitators and barriers to health • Present current legal and regulatory standards related to LGBTQ health with recommended practice protocols • Is your facility compliant?

3. LGBTIQ Definitions • Gay, Lesbian • Exclusive physical and emotional attraction to members of one’s own sex • Bisexual • Physical and emotional attraction to members of both sexes • Transgender (gender identity) • A person who feels his or her body is not the sex it should be, regardless of transformational hormone or surgical status • Cis-Gender • A person whose gender identity matches their sex at birth

4. Transgender(gender identity) LGBTIQ • MtF = Male-to-Female (she) transwoman • Born with male anatomy, female gender • FtM = Female-to-Male (he) transman • Born with female anatomy, male gender

5. Definitions LGBTIQ • Intersex • The vogue term for hermaphrodite. People born with the sexual characteristics of both sexes • Questioning • People who suspect they might be LGBT, but are not yet certain • Queer • Inclusive term of the LGBTIQ community • Unique paradigm

7. Prevalence - 9 million LGBT people in the U.S. Homosexual (gay/lesbian is preferred term) • 3.4% self-identify as LGBT (Gates & Newport 2012) • 1 in 5 - 20.8% of males in the U.S. reported either homosexual behavior or homosexual attraction since age 15 (Sell, Wells & Wypij, 1995) • 17% of women and 6% of men have engaged in same-sex behavior. However, 7% of women and 4% of men identify as gay or bisexual (Copen et al. 2016). Remember there are 320 million people in the U.S.

8. Transgender Population size • ~1.4 million adults self-identify as trans in the U.S. • Crissman et al. 2017; Flores et al., 2016; Meerwijk & Sevelius, 2017

9. Gender Non-conformity or gender Dysphoria Gender non-conformity Gender dysphoria discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) (WPATH, 2011) • the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex (IOM, 2011 definition)

10. Transgender Health – Youth • Protections under Title VII and Title IX of the Civil Rights Act. Affirmed by DOJ filing in G.G. v. Gloucester County School Board (2015).Case on appeal to SCOTUS. Oral arguments Feb. 2017. “There is a public interest in ensuring that all students, including transgender students, have the opportunity to learn in an environment free of sex discrimination.” (DOJ)

11. Transgender Health – Restroom Access • April 8, 2015 – EEOC has ruled that an employers refusal to allow a transgender employee access to restrooms consistent with his or her gender is sex discrimination under Title VII. • EEOC case: Lusardi v. AMRDEC

12. What about School? Title IX • Title IX protects students, faculty and employees from sex discrimination in any federally funded education program or activity. • However… schools are still not safe.

13. Early social transition • Child lives as gender that matches their identity • Trial run - name, attire, social roles at school, in community • Reversible • Family decision whether to disclose to others or not • Approx. 25% of children who were assessed for gender dysphoria grew up to be cis-gender gay vs. transgender.

14. Children and youth • EARLY medical and mental health services • Family support is critical to positive health outcomes • Puberty experienced congruent with gender (delay until sure) • Reduces need for later medical interventions • Prevents unwanted sex characteristics (i.e. breasts) • Decreases stress, anxiety, depression

15. Reparative therapy • = Efforts to change the sexual orientation or gender identity • Condemned by all mainstream professional organizations as harmful including the APA, AMA, Am Acad of Pediatrics, AAN, ISPN etc. • Related to depression, anxiety and suicide • George Rekers (prof emeritus from USC SOM) – published case where he conducted reparative therapy. This is what he did….

16. Puberty blocking – GnRH Agonists • Ideally begun in Tanner 2 stage (early start of puberty). • Can begin in Tanner 3-5 – goal is to stop puberty/ prevent secondary gender characteristics i.e. height, breasts etc. • GnRH Agonists - Leuprorelin; Triptorelin; Goserelin; Histrelin implants • Very expensive. Cost is between $500 and $1500 month. • Insurance rarely covers this cost • Effects are totally REVERSIBLE

17. Irreversible Hormone effects • ESTROGEN • Breast development • Nipple enlargement • Loss of erection • Testicular atrophy • ? sterility • TESTOSTERONE • Uterine atrophy • Facial and body hair • Deepened voice • Clitoral enlargement • ? sterility

18. First do no harm…. There is harm related to NOT intervening • Suicide ~ 44% • Depression • Anxiety • Homelessness • ETOH, drug use • Sex work • HIV

19. Overrepresented Health Problems • HIV/ AIDS • Trauma/ Victimization • Mental Health Concerns • Addictions • Is this because they’re LGBT? –or- because of the context within which LGBT people must exist?

20. HIV/ AIDS • A missing generation of gay men due to AIDS • HIV+ the norm in some areas • Homelessness/ poverty – survival sex • Street hormones (trans)

21. Trauma/ Victimization • Parental abuse • Increased prevalence of verbal and physical abuse and heightened suicidal ideation among those who disclosed their s.o. to their families • Hate crimes

22. Mental Health – Depression & Anxiety Additional stress d/t image management related to s.o./g.i. • LGBT children often grow up in a society that says that they should not exist and/or should not act on their feelings. • These societal mores can be internalized = internalized homophobia

23. Depression • Prevalence of depression 17.2% higher than in U.S. adult men in general • Distress & depression associated w/: • lack of a partner; • notidentifying as gay, queer, or homosexual; • experiencing multiple episodes of antigay violence in the previous 5 years; and • very high levels of community alienation Mills 2004

24. LGBT Youth Victimization • 25% of gay youth (16% lesbian) have been threatened or injured with a weapon on school property. • 3x higher than hetero rate for boys; 4x higher than hetero for girls. • 13% gay (16% lesbian) youth didn’t go to school because of safety issues (O’Malley, 2014) • 3x the hetero rate Sample was of YRBS HS students

25. Mental Health - Suicide • LGB youth = 30% attempted suicide(double the hetero rate) • School bullying increased the risk of suicide (Bouris et al, 2016)

26. Transgender Suicide U.S. Trans/GQ Data • 42% attempted suicide • Those who reported moderate to severe rejection by their family were more likely to attempt suicide (OR 2.0 to 3.2 respectively) (Drapeau, 2015)

27. Addictions Ecstacy: MDMA • Young LGBT (most prevalent) • Lesbian/ female Bi – principally ETOH • Gay/ MtF Transgender – • Ecstasy (and other Rave drugs) • Risk = hyperthermia; • Poppers (amyl nitrate) – enhanced sexual experience • Risk = an MI, priapism

28. CDC Recommendations for SCHOOLS to support LGBTQ health • Identify “safe spaces” • Prohibit harassment and bullying • Facilitate access to health & psych providers not on school property who are LGBTQ affirming • Encourage professional development on safety for all students • Provide health education curricula with inclusive terminology Demisse et al., 2013

29. CASE 1 • A 15yo questioning female student presents to the school nurse asking him to sponsor a Gay Straight Alliance (GSA) at their school. The best school nurse answer: • “yes, of course I’ll sponsor a GSA” • “I’d like to but I’ll need to talk to the principal first” • “I think I’d like to talk to your parents first – we’ll be back in touch” • “You really need to talk to our school psychologist about this”

30. SC Code 59-32-30A(5)Local school boards to implement comprehensive health education program; guidelines and restrictions • (5) The program of instruction provided for in this section may not include a discussion of alternate sexual lifestyles from heterosexual relationships including, but not limited to, homosexual relationships except in the context of instruction concerning sexually transmitted diseases.

31. Case 2 • 30yo transman who initiated social gender affirmation 5 years ago, chest construction at 25yo, testosterone from 25-28yo. He grew a beard and stopped taking T. Beard growth persisted. No menstruation for 5 years. He would like the option to become pregnant in the future because he wants children but has legal concerns related to adoption. As the NP you first: • Conduct an exam and draw labs • Conduct an exam, draw labs and refer to endocrinology • Conduct an exam, draw labs and refer to GYN

32. Your patient wants to transition – now what? The pdf is free • Google “WPATH Guidelines” • Refer to a Psych NP or other mental health provider • Start hormone therapy www.wpath.org

33. Research on hormones – is it safe? FTM MTF Increased risk of CAD at high doses. Increased risk of CA at low doses If prior MI – PO estradiol does not incr. or decr. risk for further emboli • No increase in CAD found in 876 FTM pts (Gooren, 200)

34. WPATH Standards of Care • The criteria for hormone therapy are as follows: • Persistent, well-documented gender dysphoria; • Capacity to make a fully informed decision and to consent for treatment; • Age of majority in a given country (if younger, follow the Standards of Care outlined in section VI); • If significant medical or mental health concerns are present, they must be reasonably well controlled

35. Rx information taken from Cavanaugh 2016 HormonesFtM - Options • Injectable Testosterone • Testosterone Enanthate or Cypionate 100-200 mg IM q 2 wks (20 -22g x 1 ½” needles) • Transdermal Testosterone • Androderm TTS 2-8mg daily • Topical testosterone gels in packets and pumps, multiple formulations (Testim, Androgel) 5 to 10 gm (50 to 100 mg of testosterone) applied topically daily • Axiron 2% pump gel for axillary application 1 pump to each axilla daily • Testosterone Pellet • Testopel- implant 6-10 pellets q 3 to 6 months • Buccal Testosterone • Striant 30 mg buccal system q 12 hours

36. Testosterone Risks Monitoring Baseline CBC, CMP, lipids, renal panel, fasting glucose 3 month, then Q 6-12 mo CBC, liver enzymes, serum testosterone Q 6-12 mo Lipid profile, HbA1c •  HDL  triglycerites •  insulin resistance •  sleep apnea • Infertility • Mental health changes

37. Hormones MtF options • Oral Estrogen • Estradiol (estrace) 2-6mg PO or SL daily(can be divided into BID dosing) • Premarin (conjugated estrogens) 1.25-10mg PO daily (can be divided into BID dosing) • Transdermal estrogen (preferred for 40yo) • Estradiol patch 0.1-0.4mg twice weekly • Injectable Estrogens [NOTE – shortage right now] • Estradiol valerate5-20mg IM q2 weeks • Estradiol cypionate2-10mg IM weekly • Antiandrogens • Spironolactone (aldactone) 50-400mg PO daily (can be divided into BID dosing) • Finasteride (Proscar) 2.5-5mg PO daily • Progestins – increase breast development, but CV risk, weight gain & depression

38. MtF – Estrogen Risks monitoring Baseline – CBC, CMP, lipids, renal, fasting glucose, testosterone, prolactin 6mo. – serum testosterone & estradiol If on spironolactone 1 mo. then 3mo. – lipids, lytes, creatinine, glucose • CAD weight triglycerides • libido glucose tolerance • Gallbladder ds • Infertility • Mental health changes • Spronolactone carries risks of hypotension, hyperkalemia and renal insufficiency

39. MtF Surgical Options (~30%) • Removal of scrotum & penis • Creation of vagina, labia, clitoris & mons • Breast augmentation • Tracheal shave • Facial feminization • Brow • nose Taken from Schechter 2017 p.37

40. FtM Surgical Options (~30%) • Phalloplasty with urethral reconstruction & creation of scrotum (uncommon) • Chest reconstruction

41. Staged Surgeries • Genital FtM • Tissue removal from donor site • Urethral reconstruction • Implant prosthesis • Chest Contouring FtM • Mastectomy • Revision of prior surgery to decrease scarring and remove arm flaps

42. You’re aN ORG leader/ ManagerWhat can YOU do? • Know the law and standards related to LGBTQ patients • Train your staff – receptionist to CNO • Work on the culture of your organization to make it safe.

43. Joint Commission Standards (2011) • The patient-centered communication standards for Hospitals (CAMH). • Elements of performance 28 and 29 under RI.01.01.01, require access to a support person and non-discrimination of care. The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and FamilyCentered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. Oak Brook, IL, Oct. 2011. LGBTFieldGuide.pdf.

44. RI.01.01.01 Element 29 “No longer considered to be simply a patient’s right, effective communication is now accepted as an essential component of quality care and patient safety.”

45. Hospital visitation • January 2010 Centers for Medicare and Medicaid Services(CMS) regulation required hospitals to permit patients to designate visitors & prohibits discrimination in visitation based on so/gi. 42 C.F.R. § 482.13 • Compliance with requirements for Medicare Conditions of Participation (CoPs)

46. Hospital Visitation • July 2011 Joint Commission standard – prohibition on discrimination based on orientation or gender identity. • “Prohibit discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.” RI.01.01.01 EP29 (p.48 of Joint Commission LGBT doc).

47. CMS – Equal coverage to care in the same nursing home as a spouse • Aug. 29, 2013 - CMS announced the guarantee of Medicare coverage applies to ALL spouses regardless of sexual orientation. • Prior to this same-sex spouses with Medicare Advantage plans were not eligible to live in the same nursing home as their spouse.

48. fmla • All spouses are now covered under FMLA if the employer is FMLA covered. (3/15 injunction against same sex spouses dissolved by SCOTUS Obergefell ruling) FMLA may be used for • The birth of a child, adoption or foster parent; • To care for a spouse, son, daughter, or parent who has a serious health condition; • For a serious health condition that makes the employee unable to perform the essential functions of his or her job; or • For any qualifying exigency arising out of the fact that a spouse, son, daughter, or parent is a military member on covered active duty or call to covered active duty status. http://www.dol.gov/whd/regs/compliance/whdfs28.pdf

49. Affordable Care Act • Section 1557 – Civil Rights provisions of the Act. • Applies civil rights protections to the Health Insurance Marketplace created by the ACA – and includes LGBT people

50. ACA & Preventive Care May 2015 DOL Guidance on the ACA confirms • Plans cannot limit sex-specific preventive services by gender identity. If a provider orders the service it is considered appropriate. http://www.dol.gov/ebsa/faqs/faq-aca26.html