LGBT Health

1. LGBT Health Carolyn Swope Halley, MD August 2006

2. Goals/Objectives • Goal: to improve care for LGBT patients • Objective: Improve understanding of the specific health risks affecting the LGBT community • Objective: General understanding of the health concerns affecting a transgender person • Objective: To encourage residents to be thoughtful about creating a welcoming atmosphere for LGBT patients

3. Is it important? • In a 2004 study of over 350 substance abuse counselors in Iowa and Chicago, counselors reported very little formal education regarding the needs LGBT clients, and nearly half had negative or ambivalent attitudes. • In a 2006 study of 248 medical students, those with increased clinical exposure to LGBT patients tended to perform more comprehensive histories, hold more positive attitudes toward LGBT patients, and possess greater knowledge of LGBT health care concerns than students with little or no clinical exposure.

4. Definitions • Sexual Orientation • Lesbian • Gay • WSW, MSM • Bisexual • Heterosexual • “On the D-L” • Queer

5. Definitions • Gender Identity • Transgender • Transsexual • Transitioning • FTM/MTF • Intersex • Gender Identity Disorder

6. Barriers to Health Care • Hesitancy of health care workers to ask about sexual orientation • Hesitancy of GLBT people to disclose • Lack of knowledge, comfort and research regarding specific health issues • Lack of insurance/partner benefits • Discriminatory attitudes among health care workers

7. Difficulties with GLBT Research • Defining the population • Measuring the size of the population • Sampling a population that is both small and hidden • Sampling and studying sensitive topic areas

8. Smoking • In a 2004 pop-based study of over 40,000 Ca residents, lesbians smoked at a rate 70% higher than heterosexual women • Gay men were 50% more likely to smoke than heterosexual men. • Data from the 1998 WHI indicate that about twice as many lesbians as heterosexual women reported being "heavy" smokers. • Almost 50% of the heterosexual women but only 25-33% of lesbians reported never smoking • “Project SCUM” (Sub-Culture Urban Marketing)

9. Alcohol • Early studies on alcoholism among LGBT deeply flawed • In a random sample of 772 college students in the SE US, WSW were 5 times more likely to smoke, 10 times more likely to drink, and 5 times more likely to use marijuana than heterosexual women. • Gay/bisexual men did not significantly differ from heterosexual men. • A cross-sectional telephone survey of 2000 MSM in 4 large cities reported high levels of both recreational drug (52%) and alcohol use (85%) • WHI data showed no difference in current alcohol use between lesbians and heterosexual women but a higher percentage of lesbians reported being recovering alcoholics.

10. Gay Men, “Tina,” and Risky Sex • Crystal meth provides increased self-esteem, increased libido, greater sexual endurance, diminished sexual inhibition, and a higher threshold for pain. • Estimated that methamphetamine is 5-10 times more common in urban MSM than in the general US population • About 20% of gay men in San Francisco report some meth use, as do about 15% of gay men in New York. In Chicago, nearly one in five gay men who reported using meth said they took the drug weekly. • In a recent study from an LA HIV testing clinic nearly 1/3 of recent positive tests in gay men were associated with meth use. • 1 in 5 MSM in Seattle who do crystal have HIV; this is 25% above HIV prevalence in MSM overall. 1 in 3 MSM who inject crystal have HIV.

11. Cardiovascular Risks • According to WHI, lesbians more likely than heterosexual women to have high BMI, waist circumference, waist/hip ratio • Also more likely to engage in regular exercise • Higher prevalence of MI in lesbians but lower CVA & HTN

12. Breast Cancer Risk • Older lesbian and bisexual women have similar rates of mammogram to heterosexual women, according to WHI • 2006 population based study in NY reported WSW 4 times less likely to receive mammogram • Less likely to give birth by age 30 • May use alcohol more • Higher BMI, also higher exercise

13. Ovarian Cancer • Low parity • Less OCP use • Increased smoking • Higher BMI • No evidence either way of comparative prevalence among lesbian vs heterosexual women

14. Sexually Transmitted Diseases: WSW • Overall, lower risk of STD transmission • In a survey of ~7000 lesbians, 77% had had 1 or more male partners • Some studies have reported that WSW may be more likely to have had unprotected IC, gay/bi male partners, and sexual contact with IDU • Lesbians are less likely than bisexual or heterosexual women to be tested for STD

15. Sexually Transmitted Diseases: WSW • Proven transmission: herpes, HPV, trichomoniasis, • Case reports: HIV, Hep B • Not studied, but theoretically possible: CT/GC, syphillis • Special case: BV

16. Cervical Cancer Risk • In a 2006 population based study in NY, WSW were ten times less likely than non-WSW to have received a timely Pap test • In one study, women who reported that their health care providers were more knowledgeable and sensitive to lesbians issues were significantly more likely to have had a Pap test within the last year • More likely to smoke

17. STD - MSM • 42% of new HIV cases in MSM in US, even higher percentage in King County • Re-emergent STD (syphillis, GC, CT) since 2000 in multiple cities in US • In a 2000 King County study of nearly 1000 MSM, 43% of those who had anal sex reported either "never" or only "sometimes" using condoms. Among MSM surveyed at STD clinics, rectal GC or CT was found in 10.8% of HIV- and 14.7% of HIV+ men. • Evidence of MSM making unprotected sex contacts on internet; prevention campaigns in chat rooms also successful.

18. Anal Cancer • Risks for anal cancer include anal IC and infection with multiple strains of HPV. • HIV+ gay men are at significantly greater risk for anal dysplastic lesions than HIV- gay men. • Moreover, the risk for detection and progression of dysplastic lesions grows as the CD4+ cell count declines. • ASIL risk may not decline with immune restoration with HAART

19. Mental Health • Until 1973 homosexuality was classified as a mental disorder • “The research on homosexuality is very clear. Homosexuality is neither mental illness nor moral depravity. It is simply the way a minority of our population expresses human love and sexuality. Studies of judgment, stability, reliability, and social and vocational adaptiveness all show that gay men and lesbians function every bit as well as heterosexuals.” -- American Psychological Association

20. Mental Health • In the WHI study, WSW had QOL and emotional well-being scores similar to heterosexual women. • In a NZ study of 946 people, men and women with same sex attraction reported significantly more suicidal ideation and self-harm. • Men with same-sex attraction were also significantly more likely to report having attempted suicide. • LGBT people have unique stressors: prejudice, stimatization, antigay violence

21. Intimate Partner Violence (IPV) • In a 2000 survey of over 8000 women, more than 11% of those in same-sex relationships reported having been raped, assaulted or stalked by a female partner (21% for hets) • Fewer services • Increased isolation • Concern for police harrassment • Protecting the community • Myths -- “Women aren’t violent” • Additional threats– to “out” the victim, to take children, to deport

22. Hate Crimes • American Psychological Association has determined that victims of hate crimes suffer the PTSD symptoms for up to five years, in comparison to two years for victims of non-bias-related crimes. • Survivors of hate crimes are less likely than victims of other types of violence to report attacks against them to the police. • Estimated that up to 80% of bias-crimes are never reported to the authorities

23. Transgender Health Concerns • Understanding of transgender health barriers • Care of the initial anatomical sex • Care of anatomical changes • Resulting from hormone therapy (HT) • Resulting from surgery

24. Harry Benjamin International Gender Dysphoria Association (HBIGDA) Standards of Care for Hormone Initiation • Able to give informed consent • Informed of anticipated effects and risks • Completion of either 3 months “RLE” or psychotherapy for duration specified by assessor (usually min 3 months) Same for breast/chest surgery Standards of Care for genital/lower surgery • At least 1 yr RLE

25. Effects of Testosterone on FTM • a permanent deepening of the voice • decreased fertility--menstrual cycles becomes irregular and eventually stop • permanent clitoral enlargement • mild breast atrophy (but not substantial reduction in size) • increased upper body strength with exercise • Facial hair growth • male-pattern baldness • increased sexual interest and arousal • redistribution of fat from hip toward waist • Development of acne, similar to male puberty

26. Side Effects of Testosterone • acne • increased emotional sensitivity and/or instability • shift of lipid profiles to male patterns which increase cholesterol and the risk of cardiovascular disease • the potential to develop benign and malignant liver tumors and liver dysfunction

27. Effects of Estrogen on MTF • breast growth • some redistribution of body fat to approximate a female body shape • decreased upper body strength • softening of skin • decrease in body hair • slowing or stopping the loss of scalp hair • decreased fertility and testicular size • less frequent, less firm erections

28. Side Effects of Estrogen • increased propensity to blood clotting (venous thrombosis with a risk of fatal pulmonary embolism) • development of benign pituitary tumors • infertility • weight gain • increased emotional sensitivity and/or instability • liver disease

29. Sexual Reassignment Surgery: FTM • “Top Surgery”: Chest reconstruction • “Bottom Surgery”: Metoidioplasty, Phalloplasty

30. Sexual Reassignment Surgery: MTF • Top Surgery: breast enlargement • Bottom Surgery: bilateral orchiectomy, vaginoplasty • Other: Tracheal shave, rounding of brow, chin surgery, jaw surgery

31. Intersex • Encompases a variety of conditions in which a person is born with a reproductive or sexual anatomy that doesn’t fit the typical definitions of female or male. • ISNA • Intersexuality is primarily a problem of stigma and trauma, not gender. • The child is the patient, not the parents. • Professional mental health care is essential. • Honest, complete disclosure is good medicine. • All children should be assigned as male or female, without surgery.

32. Medicolegal Issues • In most states, hospital visitation, notification, durable POA, and parental rights for nonbiological partners are not automatically granted to same-sex couples without legal action. • Gay and lesbian people may be less linked to their families of origin, but often have larger social networks (“fictive kin”) • Partners and friends of GLBT people have pointed time and again to the lack of rights/recognition given them in relation to visiting, decision making, and caregiving for their loved one

33. Developing a Welcoming Practice • Create GLBT inclusive intake and assessment • Post non-discrimination policies & GLBT-welcoming posters. Have gay-targeted reading material in waiting room • Become familiar with appropriate GLBT community referrals • Actively reassure GLBT patients about confidentiality • Encourage visibility of GLBT employees

34. Developing a Welcoming Practice • Talk to GLBT patients about medicolegal issues. Give friends and partners of GLBT patients privileges usually given to spouse or relative. • Realize transgendered people may be particularly sensitive about disrobing. • Ask trans patients which surgeries, if any, they have undergone and do screening appropriate to birth gender as well as trans-gender. • Ensure GLBT employees have same benefits as other employees • Ensure all staff are culturally competent

35. Take-Home Pearls • MSM & WSW have higher rates of smoking cigarettes, and probably of alcohol use • WSW need PAP screening, and may not know they do • Bacterial STD may be less frequent than among heterosexual women, but do exist • WSW may have more risk factors for breast and ovarian cancers than heterosexual women

36. Take-Home Pearls • Unprotected sex and STD rates are increasing among urban gay men • Crystal meth is widely used among MSM, and it is strongly associated with risky sex and HIV • IPV occurs in the LGBT community (though less frequently than among heterosexuals) • Seattle is an international center for transgendered people, and you may have them in your practice now and in the future

37. Take-Home Pearls • Provider factors including visibly welcoming atmosphere and inquiring about sexual orientation are strongly associated with disclosure among GLBT patients • Disclosure is associated with regular health care use.

38. Local Resources • Seattle Counseling Services- mental health care for GLBT people • Northwest Network – support for GLBT survivors of intimate partner violence • Ingersoll Gender Center – support and advocacy for transgendered people • Lambert House – GLBT youth center • Capitol Hill Alano Club – gay 12-step groups • Public Health– Seattle & King County. http://metrokc.gov/health/glbt/providers

39. References • Tang, H., Greenwood, G. L., Cowling, D. W., Lloyd, J. C., Roeseler, A. G., & Bal, D. G. (2004). Cigarette smoking among lesbians, gays, and bisexuals: How serious a problem? (United States). Cancer Causes & Control, 15, 797-803. • Picketty, C. High prevalence of anal squamous intraepithelial lesions in HIV-positive men despite the use of highly active antiretroviral therapy. Sex Transm Dis. 2004 Feb;31(2):96-9. • Doolan, D. Efficacy of Smoking Cessation Intervention Among Special Populations: Review of the Literature From 2000 to 2005. Volume 55(4) Supplement 1, July/August 2006, pp S29-S37 • Valanis, BG. Sexual orientation and health: comparisons in the women's health initiative sample. Arch Fam Med. 2000 Sep-Oct;9(9):843-53. • Romanelli, F. Use of club drugs by HIV-seropositive and HIV-seronegative gay and bisexual men. Top HIV Med. 2003 Jan-Feb;11(1):25-32. • Cox, Spencer. Risky Business. The Body (online). Winter 2005-06. • Shoptaw, S. Methamphetamine use in urban gay and bisexual populations. Topics in HIV Med. 2006 Jun-Jul;14(2):84-7.  

40. Stall, R. Alcohol use, drug use and alcohol-related problems among men who have sex with men: the Urban Men's Health Study. Addiction. 2001 Nov;96(11):1589-601 • Koh. Mental Health IssuesA Comparison of Lesbian, Bisexual and Heterosexual Women. J Homosex. 2006;51(1):33-57. • Mravcak, S. Primary Care for Lesbians and Bisexual Women. American Family Physician. July 15, 2006. p279. • Cochran SD. Cancer-related risk indicators and preventive screening behaviors among lesibnas and bisexual women. Am J public Health 2001; 91: 591-7 • Roberts SA. Cardiovascular disease risk in lesbian women. Womens Health Issues. 2003 Jul-Aug;13(4):167-74. • Marrazzo J. Characterization of vaginal flora and bacterial vaginosis in women who have sex with women. J Infect Dis. 2002 May 1;185(9):1307-13. Epub 2002 Apr 16.