Fair use guidelines:

1. Fair use guidelines: • This presentation was built on a skeleton of the American Medical Student Association’s LGBT Local Project in a Box presentation called “LGBT 101” (http://www.amsa.org/AMSA/Homepage/About/Committees/GenderandSexuality/LGBT_PIB.aspx) and premade slides from the Fenway Institute. • You may modify the presentation without permission, but somewhere please credit both AMSA Local Projects in a Box and PRIDE in Healthcare. The Fenway Institute asks that its slides not be modified. • Also, please tell us at PRIDE in Healthcare via email that you are using our materials (prideinhealthcare@gmail.com). • You may find more resources developed by us and by others at our blog, http://uwmedstudents.com/prideinhealthcare.

2. Cultural Competency Workshop I:Overview of LGBT Health James Lehman, MD Candidate President, PRIDE in Healthcare October 23rd and 25th, 2012

3. Outline • Linguistic competency • Demographic and cultural considerations • Medical issues, health disparities, and health determinants • LGBT in the clinic: How to ensure positive encounters

4. Terminology • There are many terms sexual and gender minorities use to describe themselves • Some widely accepted; others more obscure or controversial • Respect language choices and the right to self-identification • LGBTQIAA+: for every letter, there are people for whom the word is an important identity • The so-called LGBT community is not one monolithic entity

5. Sex versus gender Sex and gender are intertwined but distinct concepts. • Sex: genetic or anatomical distinction between male and female • Gender: the societal construct that is associated with men (masculinity) and women (femininity) • Gender identity: internal feelings of masculine or feminine identity–or both, or neither • Gender expression: outward expression of gender identity • Gender identity & expression are substantially culture-dependent

6. Sexual orientation versus sexual behavior • Sexual orientation: an enduring pattern of attraction—emotional, romantic, sexual, or some combination of these—to the opposite sex, the same sex, both, or neither, and/or the genders that accompany them • Sexual behavior:specific sexual practices in which one engages, including • anatomical sex of partner(s) • gender(s) of partner(s) • body parts or accessories (toys) used • use of contraception/STI protection • relationship status with partner(s) • Epidemiologic categories reflect behavior • MSM (men who have sex with men) • MSMW (men who have sex with men & women) • WSW • WSMW

7. Sexual Attraction Sexual Orientation Paradigm of Sexuality Sexual Behavior Biological Sex Gender Identity/ Expression

8. Lesbian Gay Bisexual Transgender Queer or questioning Intersex Asexual Allies

9. Transgender • Transgender: people whose gender identity differs from sex assigned at birth • Transsexual: identifies with a gender other than the birth gender, often transitions hormonally or surgically • Gender Bender/Genderqueer: do not easily fit into binary gender categories; may have a mix of masculine and feminine characteristics

10. (Not Really) Transgender • Crossdresser: gender identity matches assigned gender but occasionally dresses as and may take on the mannerisms of the opposite gender • Performer: dresses as the opposite sex for entertainment or for work; may or may not identify as transgender. Some are drag queens(often gay men dressing as women) or drag kings (often lesbians dressing as men) The Kinsey Sicks America's Favorite Dragapella®Beautyshop Quartet

11. Transwhatnow? • FTM = female to male • Called a transman because he is a transgender person identifying as a man • MTF = male to female • Called a transwoman because she is a transgender person identifying as a woman • Trans people almost always prefer the pronouns of their self-identified gender • Some prefer gender-neutral pronouns like ze/hir/hirs/hirself

12. Intersex • Someone with intermediate or atypical combinations of physical or biological features that usually distinguish female from male. • Usually congenital (chromosomal or genital/gonadal) anomalies • Their needs and problems overlap somewhat with LGBT, but medical and ethical issues are unique.

13. Queer (umbrella) vs. Queer (Genderqueer) • Queer can be shorthand for genderqueer • Queer can refer to all sexual/gender minorities • Not mutually exclusive with LGBT+ identities • This is an example of reclaiming a term, making it non-perjorative • Fag and dyke are sometimes used this way • YMMV. Some people (especially older and rural) consider it only a slur • Wait for someone to self-identify as queer first • Expect it most often in younger, college-educated persons

14. A 35-year-old bisexual woman describes being physically and emotionally abused by her girlfriend. You empathize and ask for the history of this abuse. She promptly admits, “I’m worried my girlfriend will out me.” Cases

15. A 74-year-old widower comes to your office with complaints of burning during urination. When you ask about his family life, he talks about his children and grandchildren. When you ask who takes care of him when he gets sick, he mentions having a roommate. He does not admit until you ask directly that he has sex with men, even though he used to be married to a woman. He says he and his roommate are in an “open relationship.” Cases

16. Your patient is a successful, well-educated gay man who would like to have a least one biological child. He and his “husband” (they are domestic partners) are very anxious about finding a fertility clinic that will be friendly to them. Cases

17. A female patient with employer-sponsored insurance has an unemployed transman domestic partner. He has not undergone sex-reassignment surgery but they scrape together enough money for hormones. They cannot afford the sex reassignment surgery and legal proceedings that are necessary so that they can get married. Cases

18. An inebriated 25-year-old gay man arrives in the ED with a laceration on his leg. He admits severe alcohol addiction and suicidal ideation. When the first-year medical student who is present for an educational activity asks whether he is interested in a recovery program, the patient responds, “I’m sure they don’t want any faggots there.” Cases

19. A baby is born with an enlarged clitoris (clitoromegaly). She has 21-hydroxylase congenital adrenal hyperplasia (CAH). How do you inform and counsel the parents? Cases

20. An intersex patient who identifies as a woman presents with a sinus infection. She is currently involved with a genderqueerindividual who sits in the waiting room. You hear a PA in your clinic comment that “this place is turning into a freakshow.” Cases

21. A partnered 80-year-old lesbian who has been your patient for many years with left ventricular failure presents with orthopnea and exercise intolerance. You would like to enter her into UW Health's Heart Failure Management Program. She says that she does not want to go “because the nurses will abuse [her] if [her] partner visits” and “[her] partner won’t be able to visit if something bad happens.” She has been your patient for many years. She is very assertive and came out to you on your first visit but asked that her sexual orientation never be included in her medical record. Cases

22. A teenage female is romantically attracted to women. She is not sexually active but asks you for safe sex advice. Cases

23. Two lesbian parents arrive with their infant son for a well-child exam. Their son looks well, but they seem annoyed. When you ask whether something is wrong, they say that the receptionist asked, “Which one of you is the mother?” Cases

24. A 30-year-old married Latino man has had a few recent male casual sex partners but does not identify as gay or bisexual. He admits anal sex with most of the recent partners (but never as the receptive partner), and he always uses a condom during anal sex.He is worried because one of his male partners had a positive throat culture for Neisseria gonorrhoeae. Cases

25. Outline • Linguistic competency • Demographic and cultural considerations • Medical issues, health disparities, and health determinants • LGBT in the clinic: How to ensure positive encounters

30. Williams Institute, UCLA

32. Cultural background and self-identificationRACE/ETHNICITY • African American men have used SGL (same-gender loving) and on the DL (down low) as alternatives to “gay,” a white identity • Hispanic heterosexually married and unmarried MSM often do not consider their behaviors homosexuality • 130+ Native American peoples have defined a mixed gender identify (e.g., two-spirit)

33. Cultural background and self-identification • Up to half of lesbians are or have been heterosexually married • Some WSW with female partners identify as heterosexual • Older generations less likely to disclose identity • Experienced criminalization • Pathologization by psychiatry • Fear of reparative therapy or other mistreatment

34. Cultural background and risks • Sexual minority + racial/ethnic minorities = compounded effects of discrimination and lack of privilege (minority stress) • Other characteristics that affect disclosure of identity and sex behaviors: education level, income, geographic location, language, immigration status, knowledge, and cultural beliefs

35. Leading health indicators for sexual minorities In Healthy People 2010, the Department of Health and Human Services identified ten leading health indicators (determinants) in the US population. Seven were particularly relevant to sexual and gender minorities. • Physical activity • Overweight and obesity • Tobacco use • Substance abuse • Responsible sexual behavior • Mental Health • Injury and violence • Environmental quality • Immunization • Access to care

37. Outline • Linguistic competency • Demographic and cultural considerations • Medical issues, health disparities, and health determinants • LGBT in the clinic: How to ensure positive encounters

38. Research disparities • Health care barriers • Institutional/structural • Provider • Patient • Minority stress • Biology LGBT patient healthOVERVIEW

40. Minority stress: Prejudice and discrimination are chronic social stressors • Distal stress processes are external, including experiences with rejection, prejudice, and discrimination • Proximal stress processes are internal and often the byproduct of distal stressors: concealment of minority identity, vigilance and anxiety about prejudice, and negative feelings about one’s own minority group LGBT patient healthMINORITY STRESS

41. Meyer IH. Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. PsycholBull. 2003 September; 129(5): 674–697.

42. LGBT health concernsSOCIAL CONDITIONS & MENTAL HEALTH • Often victims of violent physical assaults and other forms of abuse • Substance abuse • Unique fertility concerns • Intimate partner violence • Stresses resulting from depression, anxiety, suicide

43. O’Hanlan KA et al. A Review of the Medical Consequences of Homophobia with Suggestions for Resolution. J Gay Lesbian Med Assoc. 1997; 1(1):25-39.

44. LGBT health concernsLGBT Youth • Lack healthy outlets for sexual exploration • Far more likely to smoke • Far more likely to become homeless • Verbal and physical violence • Several times more likely to be threatened or injured with a weapon at school • Suicide and depression • Nearly 1/3 of all adolescent male suicide attempts involve a crisis over sexual orientation • Supportive environments and people make all the difference

45. 2x as likely to live alone as other seniors • Half as likely to have a partner • 4x more likely to  have no children to assist them • 50% more likely to have no close relatives to call for help when needed • Increased rates of smoking, obesity, alcohol abuse, and HIV infection • Delay and avoid health care LGBT health concernsLGBT Elders

46. Increased risk of breast cancer • Nulliparity • Less use of hormonal “birth control” • Increased risk of other GYN cancers • Pap intervals up to 3x longer than heteros • Inactivity + obesity + smoking + stress= cardiovascular risk • STIs • Often ignored in WSW; screening just as important • HSV, HAV and HBV, HPV, chlamydia, gonorrhea, and HIV • Common vaginal infections: Yeast infections, trichomoniasis, bacterial vaginosis Lesbian health

47. STIs • MSM are at higher risk of both HAV (oral-fecal) and HBV (sexual contact)—Immunize! • MSM youth are particularly vulnerable to STIs • Illicit drug use • Raises chances of unsafe sexual behavior • Needle sharing directly transmits infections • Eating and body image disorders • Anal cancer (35x heterosexual men) • Often caused by HPV, but immunocompromised men at higher risk • Gay men who have receptive anal sex recommended to get anal pap smears Gay male health

48. Often parallel risks to gay men and lesbian women • As with MSM and WSW, STIs risks reflect specific behaviors • Sometimes face marginalization in LGBT community itself • Women • Smoke more than lesbians • More mood and anxiety disorder • Less often insured than lesbians • Higher rate of injected drug use than lesbians • Screening neglect: cholesterol, mammography • Men • Rarely separated from gay men in epidemiologic analysis Bisexual health

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