Meeting the Healthcare Needs of Lesbian, Gay, Bisexual, and Transgender (LGBT) Populations: The End to LGBT Invisibility

1. Meeting the Healthcare Needs of Lesbian, Gay, Bisexual, and Transgender (LGBT) Populations: The End to LGBT Invisibility Developed by The Fenway Institute, Fenway Community Health Boston, MA in collaboration with the American Medical Association GLBT Advisory Committee 2009 With Funding From Aetna and the Gilead Foundation

2. LGBT Invisibility in Healthcare When you last saw a clinician for primary care, how many of you were asked to discuss your sexual history? sexual health? Has a clinician ever asked you about your sexual orientation? Has a clinician ever asked if you have concerns about your gender identity? How many have had discussions about LGBT health issues in school or in training? How about at CME programs? How many feel the centers where you work actively create a welcoming environment for LGBT staff and patients?

3. Learning Objectives Explain the need for enhanced education about LGBT health in light of continued stigma and discrimination Describe LGBT terminology and concepts Describe practical approaches to meeting the unique healthcare needs of LGBT people List strategies for creating a safe and welcoming environment for LGBT patients List strategies for improving the work and learning environments of LGBT health professionals and students

4. Why LGBT Health? Two Worlds

5. Growing LGBT Acceptance

6. People Left Behind

7. A Long History of Bias in Healthcare Survey of California physicians (1982 and 1999): 1982: 39% were sometimes or often uncomfortable providing care to gay patients (Mathews et al., 1986) 1999: 18.7% were sometimes or often uncomfortable providing care to gay patients (Smith and Mathews, 2007) National survey 2007 of general public: 30.4% would change providers upon finding out their provider was gay/lesbian (Lee et al., 2008) 35% would change practices if found out that gay/lesbian providers worked there 2005/6 surveys of medical students (AAMC reporter, 2007) 15% aware of the mistreatment of LGBT students at their schools 17% of LGBT students reported hostile environments

8. LGBT Demographics, Concepts, and Terminology

9. “No, we are not twins.”

10. LGB Demographics in the U.S. Identify as lesbian, gay or bisexual: 1.4 – 4.1% Same-sex sexual contact in last year: 3% (women) 4% (men) Same-sex sexual contact ever: 4.3 -11.2% (women) 6 - 9.1% (men) (Laumann et al.,1994; Mosher et al., 2005) Same-Sex Couples in the United States Same-Sex Households (Makadon, 2006); Map Courtesy of J. Bradford PhD. and K. Barrett PhD., SERL, VCU Makadon, H. J. N Engl J Med 2006;354:895-897

11. There is diversity of expression in our own communities and globally

12. Understanding Sexual Orientation Identity Behavior Attraction 12

13. Discordance between Sexual Behavior and Self -Reported Identity 2006 study by the NY Department of Mental Health sample of 4193 men in NYC 9.4% of men who identified as straight had sex with a man in the prior year More likely to belong to minority racial and ethnic groups, be of lower socio-economic status, be foreign born Less likely to have used a condom (Pathela, 2006) 77-91% of lesbians have had at least one prior sexual experience with men 8% in the prior year (O’Hanlan, 1997)

14. Transgender: The T in LGBT People who persistently identify and/or express their gender as the opposite of their biologic birth sex and often have hormonal and surgical treatment (sometimes called transsexualism) People who define themselves as a gender outside the either/or construct of male/female – e.g., having no gender, being androgynous, or having elements of multiple genders (some use the term genderqueer) People who enjoy the outward manifestations of various gender roles and cross dress to varying extents (some use the term cross-dressers) 14

15. Alternative Constructs of Gender Identity:Terminology Follows Concept Identity Begins Here Identity Begins Here Medical Construct Gender Reassignment or Transitioning Individual Construct Gender Affirmation

16. Sexual and Gender Minorities The terms “sexual minorities” and “gender minorities” are used increasingly Why “minority”? Research / epidemiology: important to define population groups experiencing health disparities Policy change: minority group membership important for achieving protections against discrimination Some LGBT people dislike being called a “minority” 16

17. Getting to Know Your Patients

18. How well do you know your patients? New Patient New Lesbian Patient How do you feel when learning this?

19. Taking a History The core comprehensive history for LGBT patients is the same as for all patients (keeping in mind unique health risks and issues of LGBT populations) Get to know your patient as a person (e.g., partners, children, jobs) Avoid judgment or bias Assure confidentiality – and ask permission to include sexual orientation and gender identity on medical chart

20. Communicating with Patients Mirror the patients’ language: how do they identify their sexual orientation and partners? Their gender? Use gender neutral terms and pronouns when referring to partners, unless you are sure “Do you have a partner or spouse? Are you currently in a relationship? What do you call your partner?” Use the pronoun that matches the person’s gender identity If you slip up, apologize and ask the patient what term is preferred

21. Learning about Identity, Behavior, and Desire through the Sexual History Explain to patients that the sexual history is routine and confidential: “I am going to ask you some questions about your sexual health that I ask all my patients. The answers to these questions are important for me to know to help keep you healthy. Like the rest of this visit, this information is strictly confidential.” Ask about sexual health as well as behavior (e.g., satisfaction with sexual function) Assess comfort with sexuality “Do you have any concerns or questions about your sexuality, sexual identity, or sexual desires?”

22. The Sexual History, cont’d Assess sexual behavior “Have you been sexually involved with anyone during the past year, including oral, vaginal, anal sex, or other kinds of sexual practices?” “Are you sexually involved with women, men, or both?” (CCAC, 2001) “How many sexual partners have you had in the past twelve months?” Assess risk for HIV and STIs “How do you protect yourself from HIV and other STIs? (pregnancy)?” If use condoms or latex dams: “How often do you use condoms or latex dams when you have sex: all the time, most of the time, once in a while?” If barrier use is not consistent, ask: “When and with whom do you not use condoms or latex dams?” “Do you use alcohol or drugs when you have sex?”“Does your partner(s)?” 22

23. Gender Identity Ask all patients about gender identity concerns – make it routine: “Because so many people are impacted by gender issues, I have begun to ask everyone if they have any concerns about their gender. Anything you do say about gender issues will be kept confidential. If this topic isn’t relevant to you, tell me and I’ll move on.”(Feldman and Goldberg, 2006) Or ask: “Out of respect for my clients’ right to self-identify, I ask all clients what gender pronoun they’d prefer I use for them. What pronoun would you like me to use for you?”(Feldman and Goldberg, 2006)

24. Understanding Desire: Support for “Coming Out” Can happen at any age regarding sexual orientation or gender identity Ask patients who are coming out if they have family and community supports Resources: Youthresource.com PFLAG.org HRC.org

25. The Core of the Cross-cultural Interview Respect Empathy Curiosity Adapted from Betancourt and Green

26. Health Disparities and Specific Concerns in LGBT Populations

27. Background: Disparities in LGBT Health Research so far: Growing but limited number of studies; methodological issues Institute of Medicine Report on Lesbian Health conclusions (1999): Enough evidence to support more research; develop better methods of conducting that research Healthy People 2010 goal: Eliminate health disparities that occur due to differences in sexual orientation Future research on range of LGBT health issues: The Population Center at The Fenway Institute Other institutions across the nation

28. LGB Youth (12-24 years) Primary Health Concerns: Smoking Homelessness Suicide attempts Risk of being bullied, threatened, sexually coerced Lack of family support Higher levels of parental rejection associated with higher rates of attempted suicide, drug use, depression, and unprotected sex (Ryan, et al, 2009) For tips, see the Family Acceptance Project website: http://familyproject.sfsu.edu/.

29. Lesbian and Bisexual Women: Health Concerns Smoking Alcohol abuse Obesity / Excess weight Mental health Cardiovascular disease Cancer prevention Cervical; Breast STI’s: HPV, HSV 1, BV, Trichomonas, ? HIV Personal safety hate crimes, sexual and domestic violence Screen according to current guidelines

30. Gay and Bisexual Men: Health Concerns Smoking Recreational drug use (alcohol abuse?) marijuana, inhalants, ketamine, GHB and cocaine Crystal methamphetamine: growing use and concern Use in conjunction with sex raises risk of HIV/STIs Sexually transmitted infections (STIs) and viral hepatitis Anal cancer Mental health Personal safety hate crimes, sexual and domestic violence Screen according to current guidelines

31. STI Screening in MSM (CDC) Sexually active MSM should be tested for STIs annually Or every 3-6 months if have multiple or anonymous partners, use illicit drugs in conjunction with sex, or use methamphetamine: HIV (serology) Syphilis (serology) Urethral gonorrhea (culture or NAAT*) and Chlamydia (NAAT) if had insertive intercourse in past year; Rectal gonorrhea and Chlamydia (culture) if had receptive anal intercourse in past year; Pharyngeal gonorrhea (culture) if had receptive oral intercourse in past year *nucleic acid amplification test

32. STI Screening in MSM (CDC), cont’d. Vaccinate against hepatitis A and B (unless previous infection or immunization is documented) Consider HSV-2 testing (type-specific serology) if infection status is unknown Anal Pap not yet recommended by CDC (but some experts do recommend it) HPV vaccine in men being evaluated

33. Safer Sex Counseling Guidance Behavioral risk /harm reduction approaches: Abstinence Monogamy with uninfected partner Reduce number of partners Low-risk sexual practices Consistent and correct use of barrier methods Cease engaging in one form of high-risk activity Avoid excessive substance use Advise having a proactive plan to protect self and partners Counsel on correct use of barrier protection Educate on availability of post-exposure prophylaxis (PEP) for high-risk HIV exposure (e.g. condom break, post-coital HIV disclosure)

34. Anal Cell Carcinoma: Screening No consensus on whether to screen No randomized trials; no formal guidelines except NY State AIDS Institute (www.guideline.gov) Rationale for screening: Rates in MSM similar to CSCC in women before routine Pap Effective screening modalities Morbidity and mortality related to anal cancer Cost effectiveness (Kreuter and Wieland, 2009; Palefsky, 2009; Goldie et al., 2000; Volberding, 2000)

35. Whom and How to Screen Whom to screen? HIV infected men and women (yearly) MSM with high-risk behavior Transplant recipients Women with cervical cancer, high grade lesions Need larger studies for definitive guidance How to screen? Anal Pap Follow Up High Resolution Anoscopy (HRA) Digital Rectal Examination (Ryan et al., 2000; Goldie et al., 2000; Palefsky J et al. 2008, Palefsky 2008; Kreuter and Wieland, 2009)

36. LGB Mental Health Concerns Gay and bisexual men have higher prevalence of: Depression Panic attacks Suicidal ideation Psychological distress Body image/eating disorders (Siever, 1994; Kaminski et al, 2005) Lesbian and bisexual women have higher prevalence of: Generalized anxiety disorder Depression Antidepressant use Psychological distress As compared to self-identified heterosexuals (Cochran et al 2003): Screen for disorders; assess comfort with sexual identity; social supports

37. Transgender Health Concerns Smoking Alcohol and recreational drug use Mental health Suicide, isolation, depression, anxiety, gender dysphoria HIV/ STIs Personal safety hate crimes, sexual violence, homelessness Self treatment with hormones; silicone; other therapies Cancer; Cardiovascular disease

38. Transgender Standards of Care Mental health evaluation Hormone therapy Age at start?; level of feminine/masculine?; side effects Surgery for gender affirmation WPATH: Standards of Care www.wpath.org Vancouver Coastal Health (UBC) http://www.celebratevgh.ca/transhealth/ Endocrine Society http://www.endo-society.org/guidelines

40. Life Cycle: Family Matters! Marriage / Commitment Reproduction Parenting Legal Issues

41. Life Cycle: “Aging and Gay, and Facing Prejudice in Twilight” Isolation and fewer family or community supports Less likely to be “out” than younger LGBT Discrimination in long-term care facilities Need for advance directives – death of partner can bring great strain and confusion Jane Gross, The New York Times, October 9, 2007

42. Creating Change at Home: Better Environments for Caring, Learning, and Working

43. Assessing the Current Environment Do you know if LGBT patients feel welcome and feel safe to disclose their sexual behavior and identity? Do you know if LGBT students, trainees, faculty, and staff feel safe and accepted? Does everyone feel comfortable being themselves? Can everyone talk freely with colleagues? Are students and professionals being taught about LGBT health needs?

44. The Patient Environment Create intake forms that include the full range of sexual and gender identity and expression Ensure confidentiality on forms Train all staff to be respectful of LGBT clients, and to use clients’ preferred names and pronouns Post non-discrimination policy inclusive of sexual orientation and gender identity Display images that reflect LGBT lives (e.g., posters with same-sex couples, rainbow flags, trans symbol) Provide educational brochures on LGBT health topics Offer unisex bathrooms

45. Enhancing Healthcare=Enhancing Human Rights

47. Resources AMA GLBT Advisory Committee: www.ama-assn.org Training video on taking a sexual history Sample non-discrimination policy The Fenway Institute: www.lgbthealtheducation.org LGBT Health Learning Modules Links to many other resources for providers and consumers Gay and Lesbian Medical Association: www.glma.org Pamphletwith guidelines for providers on LGBT health The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. American College of Physicians, 2008. (order from Amazon.com or acponline.com)